Healthcare Provider Details

I. General information

NPI: 1790213593
Provider Name (Legal Business Name): OGANO DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 01/11/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14225 SULLYFIELD CIR STE A
CHANTILLY VA
20151-1688
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 703-263-0215
  • Fax: 703-378-7692
Mailing address:
  • Phone: 615-320-4214
  • Fax: 866-944-3352

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