Organization
SHADE DIALYSIS LLC
Active
Other names
Wagoner Dialysis
Organization subpart
No
Provider details
NPI number
Authorized official
SAMUEL T WEY (VP, LICENSURE & CERTIFICATION)
(615) 341-6641
Entity
Organization
Contact information
Practice address
402 SOUTH WALL STREET, WAGONER, OK 74467-5003
(918) 485-4363
(918) 485-3043
Mailing address
5200 VIRGINIA WAY, L&C DEPT, BRENTWOOD, TN 37027-7569
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200748420A
—
OK
Enumeration date
09/01/2016
Last updated
08/25/2025
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