| Name: | Farragut Dialysis, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Foreign Limited Liability Company |
| Status: | Exists |
| Date of registration: | 07 Feb 2013 (12 years ago) |
| Entity Number: | 000-070-511 |
| Register Number: | 000070511 |
| County: | Montgomery |
| Place of Formation: | Delaware |
| Principal Address: | 2000 16TH STREETDENVER, CO 80202 |
| Principal Mailing Address: | 601 HAWAII STREETEL SEGUNDO, CA 90245 |
| Registered Office Street Address: | 641 SOUTH LAWRENCE STREETMONTGOMERY, AL 36104 |
| Registered Office Street Address ZIP Code: | 36104 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1992047450 | 2013-03-22 | 2024-03-14 | 5200 VIRGINIA WAY, L&C DEPT, BRENTWOOD, TN, 370277569, US | 2958 DORCHESTER DR, MONTGOMERY, AL, 361163193, US | |||||||||||||||||||||||||||||
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| Phone | +1 615-320-4268 |
| Fax | 8772380567 |
| Phone | +1 334-280-4980 |
| Fax | 3342801809 |
Authorized person
| Name | SAMUEL T WEY |
| Role | VP LICENSURE & CERTIFICATION |
| Phone | 6153416641 |
Taxonomy
| Taxonomy Code | 261QE0700X - End-Stage Renal Disease (ESRD) Treatment Clinic/Center |
| License Number | S5112 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 154843 |
| State | AL |
| CAGE number | Status | Type | Established | CAGE Update Date | CAGE Expiration | SAM Expiration | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 721V5 | Active | Non-Manufacturer | 2014-02-06 | 2024-03-01 | 2028-03-06 | 2024-03-01 | |||||||||||||||||||||||
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| POC | DONNA BRAWLEY |
| Phone | +1 253-382-1294 |
| Fax | +1 888-577-9570 |
| Address | 2958 DORCHESTER DR, MONTGOMERY, AL, 36116 3193, UNITED STATES |
Ownership of Offeror Information
| Highest Level Owner | Information not Available |
|---|
| Immediate Level Owner | |
|---|---|
| Vendor Certified | 2023-03-06 |
| CAGE number | 45JM2 |
| Company Name | DAVITA INC. |
| CAGE Last Updated | 2024-03-29 |
| List of Offerors (0) | Information not Available |
|---|
| Name | Role | Address |
|---|---|---|
| CORPORATION SERVICE COMPANY INC | Agent | 251 LITTLE FALLS DRIVEWILMINGTON, DE 19808 |
Date of last update: 31 Jul 2024
Sources: Alabama Secretary of State
