Healthcare Provider Details

I. General information

NPI: 1902868169
Provider Name (Legal Business Name): GREATER LAS VEGAS DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/30/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 N LAS VEGAS BLVD
NORTH LAS VEGAS NV
89030-5801
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 702-639-0469
  • Fax: 702-639-0221
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 Number492ESR
License Number StateNV

VIII. Authorized Official

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