Wakonda Dialysis LLC

Primary specialty

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

Legal business name

WAKONDA DIALYSIS LLC

Practice address

555 W State Road 164 Ste 101
Salem, UT 84653-5732

Phone

(801) 798-7903

Fax

(801) 798-7237

NPI assigned

Sep 5, 2017

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

• Mt Nebo Dialysis Doing business as

Medicare fee-for-service enrollment

Enrolled in UT

Enrollment records 1

Listed as

DaVita Mt. Nebo DialysisCCN 462551

Overall star rating

4.0 of 5

Ownership

Profit

Certified

Mar 12, 2018

Medicare certification status

ActiveFrom the Provider of Services file

Chain

DaVita

Dialysis stations

12

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 2

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

• Revere Health PC

  • Orthopaedic Surgery Physician
  • Salem, UT
  • NPI 1942233986

  Member Of

  NPD member
• Total Renal Care Inc

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Rockfrd, IL
  • NPI 1154997591

  Member Of

  NPD member

Affiliated clinicians 1

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

• David George Barlow, DO

  • Nephrology Physician
  • Provo, UT
  • NPI 1841854528

  Dialysis facility

  Care Compare affiliation Name & address match

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

{
    "created_epoch": "1504569600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730073600000",
    "number": "1992223556",
    "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": "555 W STATE ROAD 164 STE 101",
            "city": "SALEM",
            "state": "UT",
            "postal_code": "846535732",
            "telephone_number": "801-798-7903",
            "fax_number": "801-798-7237"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAKONDA DIALYSIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-05",
        "last_updated": "2024-10-28",
        "certification_date": "2024-10-28",
        "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": "1992223556",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mt Nebo Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Mt Nebo Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jamie Lee Udell, DDS
• Utah Chiropractic & Car Accident LLC
• Spencer Van Ausdal
• Kristin Van Tassell, FNP
• Natalie Voroshuck
• Brandi Walser-Sair
• Brent K Warren, RPH
• Darin Warren, PHARM.D
• Elyse West, PTA
• Suzann Whtieman, RDH

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Salem, UT
• Providers in Salem, 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 Oct 28, 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.