MEDICARE: PATUK DIALYSIS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1124671375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATUK DIALYSIS LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L&C DEPT.
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-341-5895
Fax Number	:	866-890-5560

Provider Business Practice Location Address
First Line	:	11702 VICTORY BLVD
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-3420
Country	:	US
Telephone Number	:	818-761-1304
Fax Number	:	818-761-1624

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	JAMES K HILGER
Credential	:
Telephone Number	:	253-733-4500

Provider Enumeration Date	:	07/17/2019
Last Update Date	:	07/17/2019

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