Healthcare Provider Details

I. General information

NPI: 1306240551
Provider Name (Legal Business Name): IROQUOIS DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 PARK SIERRA DR STE 108
RIVERSIDE CA
92505-3071
US

IV. Provider business mailing address

5200 VIRGINIA WAY L&C DEPT
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 951-687-3900
  • Fax: 951-687-7998
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL WEY
Title or Position: VP, LICENSURE & CERTIFICATION
Credential:
Phone: 615-341-6641