NPIMap

Organization Active NPI

Jacinto Dialysis LLC

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Ardmore, OK
National Provider Identifier
1457697575
Registry record updated Jul 17, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
JACINTO DIALYSIS LLC
Doing business as
Ardmore Dialysis Ranch
Practice address
2617 Crossroads Dr
Ardmore, OK 73401-2574
Phone
(580) 490-9844
Fax
(580) 490-9831
NPI assigned
Dec 18, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 17, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Samuel Wey
Title
VP, Licensure & Certification
Phone
(615) 341-6641

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X Primary

Addresses

Primary practice location

2617 Crossroads Dr
Ardmore, OK 73401-2574

Mailing address

5200 Virginia Way
L&C Department
Brentwood, TN 37027-7569

Other identifiers 1

IdentifierTypeStateIssuer
200519620AMedicaidOK

Other names 1

  • Ardmore Dialysis Ranch Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171127003111 OK Part A Provider - End-Stage Renal Disease Facility (ESRD) 1557515251 Practice locations: Ardmore, OK

National Provider Directory

National Provider Directory

Member of 3

Organizations this organization is a member of, according to the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1355788800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1752710400000",
    "number": "1457697575",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "L&C DEPARTMENT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370277569"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2617 CROSSROADS DR",
            "city": "ARDMORE",
            "state": "OK",
            "postal_code": "734012574",
            "telephone_number": "580-490-9844",
            "fax_number": "580-490-9831"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACINTO DIALYSIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-12-18",
        "last_updated": "2025-07-17",
        "certification_date": "2025-07-17",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "VP, LICENSURE & CERTIFICATION",
        "authorized_official_telephone_number": "615-341-6641"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200519620A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ardmore Dialysis Ranch",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Ardmore Dialysis Ranch",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ardmore, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.