MEDICARE: BASTROP 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	:	1922342187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BASTROP DIALYSIS LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L&C DEPT 4TH FLOOR
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-320-4458
Fax Number	:	877-259-3316

Provider Business Practice Location Address
First Line	:	1431 BUSINESS CENTER CT
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45410-3300
Country	:	US
Telephone Number	:	937-208-9050
Fax Number	:	937-208-9055

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	JAMES K HILGER
Credential	:
Telephone Number	:	253-280-9501

Provider Enumeration Date	:	11/12/2012
Last Update Date	:	11/12/2012

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