Healthcare Provider Details

I. General information

NPI: 1073839296
Provider Name (Legal Business Name): CERITO DIALYSIS PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7990 TRINITY RD STE 101
CORDOVA TN
38018-7730
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 901-751-3120
  • Fax: 901-751-3223
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 Number202
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0442709
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

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