Organization
PRAIRIE DIALYSIS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SAMUEL T. WEY (VP, LICENSURE & CERTIFICATION)
(615) 341-6641
Entity
Organization
Contact information
Practice address
721 W 1ST ST, TUSTIN, CA 92780-2903
(714) 544-0079
(714) 544-0071
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
—
1407233240
—
CA
Enumeration date
04/30/2015
Last updated
03/31/2026
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