SRS-Weber Valley, LLC

Primary specialty

End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X

Legal business name

SRS-WEBER VALLEY, LLC

Doing business as

SRS Dialysis of Weber Valley

Practice address

1920 W 250 N
Marriott Slaterville, UT 84404-9233

Phone

(888) 883-0265

Fax

(855) 631-0206

NPI assigned

May 20, 2021

Last updated

May 21, 2021By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Jerome S Tannenbaum, MDNPI 1346485638

Title

Ceo and Chairman of the Board

Phone

(615) 467-0140

Specialties & licenses 1

Addresses

Other names 1

• SRS Dialysis of Weber Valley Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1568037786. Details of each certification follow.

• CCN 462539 End-stage renal disease facility · Active · Name & address match · Details

End-stage renal disease facility certification: CCN 462539

Legal name

SRS-WEBER VALLEY LLC

Certification status

Active

Provider type (POS)

End-stage renal disease facility

Participating since

Aug 27, 2008

Last certification

May 31, 2023

Ownership / control type

For Profit

Multi-facility organization

SANDERLING RENAL SERVICES USA LLC

Most recent change of ownership

Nov 1, 2021

Facility address

1920 West 250 North
Marriott, UT 84404

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jerome Seymour Tannenbaum, M.D., PH.D.

  • Nephrology Physician
  • Nashville, TN
  • NPI 1346485638
  NPD (past) Authorized official

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

{
    "created_epoch": "1621468800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621555200000",
    "number": "1568037786",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 198813",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372198813",
            "telephone_number": "615-988-7881",
            "fax_number": "855-631-0206"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1920 W 250 N",
            "city": "MARRIOTT SLATERVILLE",
            "state": "UT",
            "postal_code": "844049233",
            "telephone_number": "888-883-0265",
            "fax_number": "855-631-0206"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SRS-WEBER VALLEY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-20",
        "last_updated": "2021-05-21",
        "certification_date": "2021-05-21",
        "status": "A",
        "authorized_official_last_name": "TANNENBAUM",
        "authorized_official_first_name": "JEROME",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "CEO AND CHAIRMAN OF THE BOARD",
        "authorized_official_telephone_number": "615-467-0140",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SRS Dialysis of Weber Valley",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Ageless Womens Health Ut LLC (Ageless Women's Health)
• Stacy Cazeau, FNP-BC
• Victoria Alexandria Flores, LCSW
• Madison Martinez
• Ashlee Shemenski, RDH

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Marriott Slaterville, UT
• Providers in Marriott Slaterville, UT by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.