MEDICARE: ATLANTIC 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	:	1225573777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC 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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1802 COMMERCE DR
Second Line	:
City	:	NORTH MANKATO
State	:	MN
Zip	:	56003-1800
Country	:	US
Telephone Number	:	507-387-9095
Fax Number	:	507-345-4947

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

Provider Enumeration Date	:	12/19/2016
Last Update Date	:	11/21/2024

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Directions to “ATLANTIC DIALYSIS LLC ” Practice Location

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