Healthcare Provider Details

I. General information

NPI: 1790912970
Provider Name (Legal Business Name): LLANO DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14020 SAN PABLO AVE
SAN PABLO CA
94806-3604
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 510-234-0835
  • Fax: 510-234-3854
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 Number140000209
License Number StateCA

VIII. Authorized Official

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