MEDICARE: UNIVERSITY DIALYSIS CENTER 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	110000445	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154415982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY DIALYSIS CENTER 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	:	615-238-3085
Fax Number	:	800-268-9682

Provider Business Practice Location Address
First Line	:	333 UNIVERSITY AVE
Second Line	:	STE 100
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-6533
Country	:	US
Telephone Number	:	916-920-0877
Fax Number	:	916-920-1931

Authorized Official
Title or Position	:	SR DIRECTOR LICENSURE&CERTIFICATION
Name	:	SAMUEL T. WEY
Credential	:	AO
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	09/07/2023

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