=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972907566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAZONIA DIALYSIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2014
-----------------------------------------------------
Last Update Date | 10/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2977 REDONDO AVE
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90806-2445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-988-3418
-----------------------------------------------------
Fax | 562-595-5819
-----------------------------------------------------
=====================================================
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 | VP, LICENSURE & CERTIFICATION
-----------------------------------------------------
Name | SAMUEL T. 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 | 550003170
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------