MEDICARE: MONETT 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	:	1750769832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONETT DIALYSIS LLC

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

Provider Business Practice Location Address
First Line	:	2550 W ADDISON ST
Second Line	:	SUITE A4
City	:	CHICAGO
State	:	IL
Zip	:	60618-5939
Country	:	US
Telephone Number	:	773-281-2217
Fax Number	:	773-549-2580

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

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	05/13/2025

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