Dialysis Clinic Inc.
Organization Active NPI End-Stage Renal Disease (ESRD) Treatment Clinic/Center · East Ridge, TN
NPI 1497783047 · NPPES record last updated Oct 4, 2023
Key facts
- NPI
- 1497783047
- Entity type
- Organization (NPI type 2)
- Primary specialty
- End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X
- License
- 0000000050 (TN)
- Legal business name
- DIALYSIS CLINIC INC.
- Practice address
- 6104 N Mack Smith Rd
East Ridge, TN 37412-3960 - Phone
- (423) 894-8133
- Fax
- (423) 894-8337
- NPI assigned
- Jun 30, 2006
- Organization subpart
- No
Authorized official
- Name
- Mr. Donovan Schultz
- Title
- President
- Phone
- (615) 327-3061
Corporate family (same tax ID) 24
Affiliated clinicians 1
Medicare Care Compare: Dialysis facility
- Listed as
- Dci East Ridge
- Overall star rating
- ★★★☆☆ 3.0 of 5
- Ownership
- Non-profit
- Certified
- Oct 1, 1980
- Medicare certification status
- Active
- Chain
- Dialysis Clinic, Inc.
- Dialysis stations
- 16
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D0310329 | Dialysis Clinic Inc-East Ridge | Certificate of waiver | Jan 3, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TN
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Rancho Dialysis Clinic |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control (100%) |
Dec 24, 2003 Dec 24, 2003 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20060419000080 | TN | Part a Provider - End-Stage Renal Disease Facility (ESRD) | 4284541129 | Practice locations: East Ridge, TN |
National Provider Directory
- Tax ID family
- Elbert P Tuttle Jr MD
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| End-Stage Renal Disease (ESRD) Treatment Clinic/Center | 261QE0700X | 0000000050 | TN | Yes |
Addresses
Primary practice location
6104 N Mack Smith Rd
East Ridge, TN 37412-3960
Mailing address
6104 N Mack Smith Rd
East Ridge, TN 37412-3960
Phone (423) 894-8133
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 044-2514 | Medicaid | TN | |
| 62085048-17 | Medicaid | IL | |
| 00551867A | Medicaid | GA | |
| 000551867B | Medicaid | GA |
Other providers in East Ridge, TN
- Crossroads Urgent Care, PLLC
- Karon Annette Culp
- Laurie Deanne Davis
- Tamara Karaba Davis
- Kara Debord
- Wendy Kay Dodd
- DT Transportation
- Liliya Aleksandrovna Dundiy
- Patrick Marsh Durham
- Bruce E Dyer Sr.
All providers in East Ridge, TN · End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 4, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.