MEDICARE: TARGHEE 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	:	1417550476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TARGHEE DIALYSIS, LLC

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

Provider Business Practice Location Address
First Line	:	1550 GOODMAN AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45224-1005
Country	:	US
Telephone Number	:	513-538-3768
Fax Number	:	513-538-3769

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

Provider Enumeration Date	:	11/20/2020
Last Update Date	:	06/12/2025

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