SHADE DIALYSIS LLC NPI 1215483862

NPI Information

NPI: 1215483862
Provider Name: SHADE DIALYSIS LLC
Classification: Clinic/Center - 261QE0700X
Specialization: End-Stage Renal Disease (ESRD) Treatment
Entity Type: Organization
:
CLIA Number: 37D2121594
Address: 402 SOUTH WALL STREET
WAGONER, OK
ZIP 74467
Phone: (918) 485-4363

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NPI Details

SHADE DIALYSIS LLC is an end-stage renal disease (esrd) treatment clinic center in Wagoner, OK. SHADE DIALYSIS LLC NPI is 1215483862. The provider is registered as an organization entity type.
The provider .

The provider's business location address is:

402 SOUTH WALL STREET
WAGONER, OK
ZIP 74467-003
Phone: (918) 485-4363
Fax: (918) 485-3043

The provider's authorized official is Samuel T Wey .
The authorized official title is Vp, Licensure & Certification and has the following contact phone number (615) 341-6641.

The CLIA number assigned to this NPI record is 37D2121594 - end stage renal disease dialysis facility with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 9/1/2016 and was last updated on 8/25/2025.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	261QE0700X	Clinic/Center	End-Stage Renal Disease (ESRD) Treatment			Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	200748420A	MEDICAID	OKLAHOMA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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