Organization
SOUTHLAKE DIALYSIS LLC
Active
Other names
Broken Arrow Dialysis Center
Organization subpart
No
Provider details
NPI number
Authorized official
SAMUEL WEY (VP LICENSURE & CERTIFICATION)
(615) 341-6641
Entity
Organization
Contact information
Practice address
1710 N 9TH ST, BROKEN ARROW, OK 74012-8283
(918) 355-0657
(918) 355-2800
Mailing address
5200 VIRGINIA WAY, ATTN: 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
—
200509720A
—
OK
Enumeration date
12/27/2012
Last updated
05/01/2025
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