Healthcare Provider Details

I. General information

NPI: 1982607156
Provider Name (Legal Business Name): TRI-CITIES DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 RANDALL RD
GENEVA IL
60134-4200
US

IV. Provider business mailing address

1300 WATERFORD DR LOWR LEVEL
AURORA IL
60504-5502
US

V. Phone/Fax

Practice location:
  • Phone: 630-262-1306
  • Fax:
Mailing address:
  • Phone: 630-851-1206
  • 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: MR. CALVIN GANONG
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 630-851-1206