=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720515331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLOSS DIALYSIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2017
-----------------------------------------------------
Last Update Date | 10/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5414 FM 1960 RD E
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77346-2627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-445-0020
-----------------------------------------------------
Fax | 832-445-1335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L&C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-320-4224
-----------------------------------------------------
Fax | 800-293-4707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR DIRECTOR 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 |
-----------------------------------------------------