Provider Demographics
NPI:1932353950
Name:SOUTHWEST KIDNEY DAVITA DIALYSIS PARTNERS, LLC
Entity type:Organization
Organization Name:SOUTHWEST KIDNEY DAVITA DIALYSIS PARTNERS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR LICENSURE&CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6814
Mailing Address - Fax:800-293-8405
Practice Address - Street 1:8910 N 43RD AVE
Practice Address - Street 2:STE 107
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-5340
Practice Address - Country:US
Practice Address - Phone:623-937-2735
Practice Address - Fax:623-937-2758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ481882Medicaid
AZ032630Medicare Oscar/Certification