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General NPI Number Information
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NPI Number | 1568421865
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Entity Type | Organization
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Legal Business Name | ELK GROVE DIALYSIS CENTER LLC
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Dates
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Enumeration Date | 03/23/2006
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 9281 OFFICE PARK CIR STE 105
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City | ELK GROVE
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State | CA
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Zip | 95758-8069
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Country | US
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Telephone | 916-691-0480
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Fax | 916-691-0488
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Provider Business Mailing Address
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Address Line | 5200 VIRGINIA WAY ATT: L&C DEPT
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City | BRENTWOOD
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State | TN
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Zip | 37027-7569
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP LICENSURE & CERTIFICATION
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Name | SAMUEL T. WEY
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Credential |
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Telephone | 615-341-6641
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | 110000518
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License Number State | CA
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