Healthcare Provider Details

I. General information

NPI: 1801507702
Provider Name (Legal Business Name): ON SITE DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 WREN ST
HERNANDO MS
38632-4433
US

IV. Provider business mailing address

PO BOX 382926
GERMANTOWN TN
38183-2926
US

V. Phone/Fax

Practice location:
  • Phone: 662-806-7480
  • Fax:
Mailing address:
  • Phone: 662-806-7480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: AMY BLAGG
Title or Position: CREDENTIALING
Credential:
Phone: 901-821-0338