1629015979 NPI number — RENAL CENTER OF MOUNTAIN HOME LLC

Table of content: (NPI 1629015979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629015979 NPI number — RENAL CENTER OF MOUNTAIN HOME LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAL CENTER OF MOUNTAIN HOME LLC
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:
RENAL CENTER OF MOUNTAIN HOME
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:
1629015979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2023
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:
ATT: L&C DEPARTMENT
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:
615-320-4268
Provider Business Mailing Address Fax Number:
877-238-0567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 E 8TH ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72653-4402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-508-6500
Provider Business Practice Location Address Fax Number:
870-508-6550
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINSTEL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CHIEF ACCOUNTING OFFICER
Authorized Official Telephone Number:
253-733-4501

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 146280734 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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