1689643306 NPI number — RENAL TREATMENT CENTERS MID ATLANTIC INC

Table of content: (NPI 1689643306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689643306 NPI number — RENAL TREATMENT CENTERS MID ATLANTIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAL TREATMENT CENTERS MID ATLANTIC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BUENA VISTA DIALYSIS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689643306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 VIRGINIA WAY
Provider Second Line Business Mailing Address:
L&C DEPT
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-7569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-320-4286
Provider Business Mailing Address Fax Number:
866-594-2893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 EAST BURKHALTER AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BUENA VISTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31803-1701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-649-5017
Provider Business Practice Location Address Fax Number:
229-649-6410
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HILGER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CHIEF ACCOUNTING OFFICER
Authorized Official Telephone Number:
253-733-4500

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  ESRD001122 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000727394A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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