MEDICARE: DESOTO 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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285916106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESOTO DIALYSIS LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	ATT: L&C DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2702 NAVARRE AVE
Second Line	:	STE 203
City	:	OREGON
State	:	OH
Zip	:	43616-3224
Country	:	US
Telephone Number	:	419-691-1514
Fax Number	:	419-691-1594

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

Provider Enumeration Date	:	09/16/2011
Last Update Date	:	03/29/2024

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Directions to “DESOTO DIALYSIS LLC ” Practice Location

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