Healthcare Provider Details

I. General information

NPI: 1639456627
Provider Name (Legal Business Name): CABALLO DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17721 KY ROUTE 122
HI HAT KY
41636-6624
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 606-377-6393
  • Fax: 606-377-2674
Mailing address:
  • Phone: 615-341-6657
  • Fax: 866-651-9495

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: JOHN WINSTEL
Title or Position: CHIEF ACCOUNTING OFFICER
Credential:
Phone: 253-733-4501