MEDICARE: MANCHESTER 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

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	:	1184030751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANCHESTER DIALYSIS, LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L&C DEPARTMENT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-997-4210
Fax Number	:	866-935-5481

Provider Business Practice Location Address
First Line	:	3845 E LOOP 820 S
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-4337
Country	:	US
Telephone Number	:	817-496-9035
Fax Number	:	817-446-0012

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	JOHN WINSTEL
Credential	:
Telephone Number	:	253-733-4501

Provider Enumeration Date	:	07/03/2014
Last Update Date	:	09/01/2022

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Directions to “MANCHESTER DIALYSIS, LLC ” Practice Location

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