Wilder Dialysis LLC

Primary specialty

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

License

ESRD000745 Issued in GA

Legal business name

WILDER DIALYSIS LLC

Doing business as

Conyers Dialysis

Practice address

1501 Milstead Rd NE
Conyers, GA 30012-3838

Phone

(770) 761-8097

Fax

(770) 761-8141

NPI assigned

Oct 27, 2009

Organization subpart

No

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

Authorized official

Name

Samuel T Wey

Title

VP Licensure & Certification

Phone

(615) 341-6641

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Conyers Dialysis Doing business as

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

Listed as

DaVita Conyers DialysisCCN 112828

Overall star rating

2.0 of 5

Ownership

Profit

Certified

Mar 16, 2010

Medicare certification status

ActiveFrom the Provider of Services file

Chain

DaVita

Dialysis stations

16

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Member of 1

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

• Total Renal Care Inc

  dba Cascade Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Burlington, WA
  • NPI 1932595584

  Member Of

  NPD member

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

• Mazen A Abdalla, M.D.

  • Nephrology Physician
  • Snellville, GA
  • NPI 1467420893

  Dialysis facility

  Care Compare affiliation Name & address match
• Sara Husain, M.D.

  • Nephrology Physician
  • Snellville, GA
  • NPI 1912285701

  Dialysis facility

  Care Compare affiliation Name & address match

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

{
    "created_epoch": "1256601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1731369600000",
    "number": "1720314776",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "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": "1501 MILSTEAD RD NE",
            "city": "CONYERS",
            "state": "GA",
            "postal_code": "300123838",
            "telephone_number": "770-761-8097",
            "fax_number": "770-761-8141"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILDER DIALYSIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-10-27",
        "last_updated": "2024-11-12",
        "certification_date": "2024-11-12",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_middle_name": "T",
        "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": "GA",
            "license": "ESRD000745",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003101099A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Conyers Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Conyers Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Stacy Whyte-Pierre, RN
• Yolanda M Whyte, M.D.
• Illean Wiggins
• Ashley Wilcher, RBT
• Nakia Wilcher
• Steven Todd Wilder, DC
• Alexander E Williams-Green
• Latasha Janett Williams-Prince, MSN, ARPN, FNP-C
• Alicia Williams, LPC
• Andrea Williams

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Conyers, GA
• Providers in Conyers, GA by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.