Provider Demographics
NPI:1538436753
Name:GENTLE DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:GENTLE DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NABIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIRGUIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-842-5668
Mailing Address - Street 1:166 THOMPSON DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:166 THOMPSON DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1644
Practice Address - Country:US
Practice Address - Phone:304-842-5668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QE0700X261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4124162OtherMEDICARE ID-TYPE UNSPECIFIED
WV3810000048Medicaid
WV512526Medicare Oscar/Certification