Shadow Dialysis LLC

Primary specialty

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

License

110000455 Issued in CA

Legal business name

SHADOW DIALYSIS LLC

Practice address

6406 Tupelo Dr
Ste a
Citrus Heights, CA 95621-1780

Phone

(916) 721-1800

Fax

(916) 721-4376

NPI assigned

Oct 22, 2008

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

• Antelope Dialysis Center Doing business as

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Member of 1

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

• Total Renal Care Inc

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

  Member Of

  NPD member

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

{
    "created_epoch": "1224633600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1721088000000",
    "number": "1780836684",
    "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": "6406 TUPELO DR",
            "address_2": "STE A",
            "city": "CITRUS HEIGHTS",
            "state": "CA",
            "postal_code": "956211780",
            "telephone_number": "916-721-1800",
            "fax_number": "916-721-4376"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADOW DIALYSIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-10-22",
        "last_updated": "2024-07-16",
        "certification_date": "2024-07-16",
        "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": "CA",
            "license": "110000455",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1780836684",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Antelope Dialysis Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Antelope Dialysis Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Serene Residential Living
• Alexis Serrano
• Florica Sferdian, ADMINISTRATOR
• Sferdianllc
• Marcel James Shadd, COUNSELOR 1
• Palak Shah
• Elijah Andrey Shalnev
• Rimma V Shamshurina
• Nikhita Sharan Basappa
• Sandra C Shaw, L.C.S.W./A.C.S.W.

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Citrus Heights, CA
• Providers in Citrus Heights, CA by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2024; 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.