MEDICARE: RENVIVA DIALYSIS CENTER OF EASTERN PANHANDLE, 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	:	1295510071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENVIVA DIALYSIS CENTER OF EASTERN PANHANDLE, LLC

Provider Business Mailing Address
First Line	:	91 SUGAR HOLLOW RD STE E
Second Line	:
City	:	BERKELEY SPRINGS
State	:	WV
Zip	:	25411-7243
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	91 SUGAR HOLLOW RD STE E
Second Line	:
City	:	BERKELEY SPRINGS
State	:	WV
Zip	:	25411-7243
Country	:	US
Telephone Number	:	304-944-7004
Fax Number	:

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	AKINYINKA AWOSIKA
Credential	:
Telephone Number	:	321-710-0352

Provider Enumeration Date	:	08/29/2023
Last Update Date	:	05/28/2024

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