| Entity Name: | FAIRFIELD DIALYSIS, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Co. |
| Status: | Active |
| Date Filed: | 08 Dec 2011 (13 years ago) |
| Document Number: | M11000006144 |
| FEI/EIN Number | 454079774 |
| Address: | 2000 16th Street, JLD/SecGovFin, Denver, CO, 80202, US |
| Mail Address: | 601 Hawaii Street, JLD/SecGovFin, El Segundo, CA, 90245, US |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1639448467 | 2011-12-23 | 2023-11-29 | 5200 VIRGINIA WAY, L&C DEPT, BRENTWOOD, TN, 370277569, US | 929 UNIVERSITY BLVD N, JACKSONVILLE, FL, 322115529, US | |||||||||||||||||||||||||
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| Phone | +1 615-320-4593 |
| Fax | 8002935872 |
| Phone | +1 904-743-1689 |
| Fax | 9047431570 |
Authorized person
| Name | SAMUEL T WEY |
| Role | VP LICENSURE & CERTIFICATION |
| Phone | 6153416641 |
Taxonomy
| Taxonomy Code | 261QE0700X - End-Stage Renal Disease (ESRD) Treatment Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 008056600 |
| State | FL |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role | Address |
|---|---|---|
| TOTAL RENAL CARE, INC. | Auth | No data |
| Caldwell Samantha A | Auth | 2000 16th Street, Denver, CO, 80202 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G12000005312 | JACKSONVILLE ARLINGTON DIALYSIS | ACTIVE | 2012-01-16 | 2027-12-31 | No data | 929 UNIVERSITY BLVD., N., ATTN: JLD/SECGOVFIN., JACKSONVILLE, FL, 32211 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-19 | 2000 16th Street, JLD/SecGovFin, Denver, CO 80202 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-19 | 2000 16th Street, JLD/SecGovFin, Denver, CO 80202 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-19 |
| ANNUAL REPORT | 2023-04-14 |
| ANNUAL REPORT | 2022-04-19 |
| ANNUAL REPORT | 2021-04-20 |
| ANNUAL REPORT | 2020-04-20 |
| ANNUAL REPORT | 2019-04-15 |
| ANNUAL REPORT | 2018-04-16 |
| ANNUAL REPORT | 2017-04-19 |
| ANNUAL REPORT | 2016-04-19 |
| ANNUAL REPORT | 2015-04-28 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
