=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215411285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUE NORTH DIALYSIS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2018
-----------------------------------------------------
Last Update Date | 12/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 CROSSWAYS PARK DR STE 102
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11797-2044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-921-0914
-----------------------------------------------------
Fax | 516-364-0164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L & C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-341-6410
-----------------------------------------------------
Fax | 888-662-8259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP LICENSURE & CERTIFICATION
-----------------------------------------------------
Name | SAMUEL WEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-341-6641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------