Provider Demographics
NPI:1427762897
Name:BROOKSTONE DIALYSIS LLC
Entity type:Organization
Organization Name:BROOKSTONE DIALYSIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, LICENSURE & CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-320-4414
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L AND C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4414
Mailing Address - Fax:866-865-2884
Practice Address - Street 1:15 CARBON PL
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-5295
Practice Address - Country:US
Practice Address - Phone:551-285-1016
Practice Address - Fax:551-285-1343
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVITA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-10
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment