=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487682134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUNTINGTON ARTIFICIAL KIDNEY CENTER LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 12/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 N OCEAN AVE
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-289-8000
-----------------------------------------------------
Fax | 631-289-8079
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L & C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY
-----------------------------------------------------
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 | 5153202R
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------