NPIMap

Organization Active NPI

Renal Life Link Inc

Doing business as Old Forge Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Old Forge, PA
National Provider Identifier
1760444533
Registry record updated May 1, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
RENAL LIFE LINK INC
Doing business as
Old Forge Dialysis
Practice address
325 S Main St
Old Forge, PA 18518-1677
Phone
(570) 457-3174
Fax
(570) 457-3313
NPI assigned
Apr 5, 2006
Last updated
May 1, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 1, 2024

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 NU Primary

Addresses

Primary practice location

325 S Main St
Old Forge, PA 18518-1677

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
1014890420002MedicaidPA

Other names 1

  • Old Forge Dialysis Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20051208000714 PA Part A Provider - End-Stage Renal Disease Facility (ESRD) 9931162211 Practice locations: Old Forge, PA

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Old Forge DialysisCCN 392726
Overall star rating
3.0 of 5
Ownership
Profit
Certified
May 1, 2005
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
12

Name & address match This facility record has no NPI; it was connected to this NPI by matching name and address.

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
39D2165614Old Forge Dialysis325 S Main St, Old Forge, PA 18518Certificate of waiverMay 1, 2027

National Provider Directory

National Provider Directory
Tax ID family
Renal Life Link Inc32 organizations share this tax ID, including this one

Other organizations with this tax ID 31

Organizations that report the same tax identification number in the National Provider Directory.

View all 31

Locations

325 S Main St
Old Forge, PA 18518
Phone (570) 457-3174

Practitioners & affiliated clinicians

Affiliated clinicians 3

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

NPI Registry JSON

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

{
    "created_epoch": "1144195200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1714521600000",
    "number": "1760444533",
    "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": "325 S MAIN ST",
            "city": "OLD FORGE",
            "state": "PA",
            "postal_code": "185181677",
            "telephone_number": "570-457-3174",
            "fax_number": "570-457-3313"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RENAL LIFE LINK INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-05",
        "last_updated": "2024-05-01",
        "certification_date": "2024-05-01",
        "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": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1014890420002",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Old Forge Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Old Forge Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Old Forge, PA

Sources for this page

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