Organization
EDISTO DIALYSIS LLC
Active
Other names
Garden Grove Harbor 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
13054 N HARBOR BLVD, GARDEN GROVE, CA 92843-1744
(714) 539-3395
(714) 539-3467
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
550002921
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1619397700
—
CA
Enumeration date
04/16/2014
Last updated
06/07/2024
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