Provider Demographics
NPI:1548697402
Name:COLLETON DIALYSIS LLC
Entity type:Organization
Organization Name:COLLETON DIALYSIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINSTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-733-4501
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6264
Mailing Address - Fax:800-297-2925
Practice Address - Street 1:604 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-3069
Practice Address - Country:US
Practice Address - Phone:660-890-0830
Practice Address - Fax:660-890-0789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-08
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1548697402Medicaid
MO6608900830Medicaid