Healthcare Provider Details

I. General information

NPI: 1427090828
Provider Name (Legal Business Name): GREEN DESERT DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 E FLAMINGO RD STE 108
LAS VEGAS NV
89119-5191
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 702-696-9768
  • Fax: 702-791-6926
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 Number4681ESR-1
License Number StateNV

VIII. Authorized Official

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