MEDICARE: DELTA 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	:	1487422630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELTA DIALYSIS LLC

Provider Business Mailing Address
First Line	:	900 PLYMOUTH AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32805-3744
Country	:	US
Telephone Number	:	407-451-1208
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 PLYMOUTH AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32805-3744
Country	:	US
Telephone Number	:	407-824-1014
Fax Number	:	407-247-6910

Authorized Official
Title or Position	:	CEO
Name	:	NDIDI NWAMU
Credential	:	DO
Telephone Number	:	407-457-7808

Provider Enumeration Date	:	12/18/2023
Last Update Date	:	12/18/2023

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