Southlake Dialysis LLC

Primary specialty

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

Legal business name

SOUTHLAKE DIALYSIS LLC

Doing business as

Broken Arrow Dialysis Center

Practice address

1710 N 9TH St
Broken Arrow, OK 74012-8283

Phone

(918) 355-0657

Fax

(918) 355-2800

NPI assigned

Dec 27, 2012

Organization subpart

No

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

Addresses

Other identifiers 1

Other names 1

• Broken Arrow Dialysis Center Doing business as

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

Member of 1

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

• Renal Treatment Centers West Inc

  dba Lake Hefner Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Oklahoma City, OK
  • NPI 1124509245

  Member Of

  NPD member

Locations

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

{
    "created_epoch": "1356566400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746057600000",
    "number": "1568708279",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "ATTN: L&C DEPT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370277569"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1710 N 9TH ST",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740128283",
            "telephone_number": "918-355-0657",
            "fax_number": "918-355-2800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHLAKE DIALYSIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-12-27",
        "last_updated": "2025-05-01",
        "certification_date": "2025-05-01",
        "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": "200509720A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Broken Arrow Dialysis Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jack Milton Sommers, MD, MBA
• Sooner Diagnostic & Neuro Testing
• Alessandra Soto
• Maritza Soto
• South Pointe Pediatrics, PLLC
• Southside Dermatology PLLC
• Sandra Souvannachak, PHARMD
• Karen Sparks
• Lindsay R Sparks, PTA
• Rickey Joe Sparks, PHD

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Broken Arrow, OK
• Providers in Broken Arrow, OK by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 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.