Healthcare Provider Details

I. General information

NPI: 1174579619
Provider Name (Legal Business Name): ISD RENAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 MINERAL SPRING AVE
NORTH PROVIDENCE RI
02904-4025
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 401-354-5340
  • Fax: 401-353-7020
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 NumberKDT00741
License Number StateRI

VIII. Authorized Official

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