Healthcare Provider Details

I. General information

NPI: 1922342187
Provider Name (Legal Business Name): BASTROP DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2012
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 BUSINESS CENTER CT
DAYTON OH
45410-3300
US

IV. Provider business mailing address

5200 VIRGINIA WAY L&C DEPT 4TH FLOOR
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-9050
  • Fax: 937-208-9055
Mailing address:
  • Phone: 615-320-4458
  • Fax: 877-259-3316

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: JAMES K HILGER
Title or Position: CHIEF ACCOUNTING OFFICER
Credential:
Phone: 253-280-9501