1902464506 NPI number — ASHTABULA RENAL CARE GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902464506 NPI number — ASHTABULA RENAL CARE GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASHTABULA RENAL CARE GROUP, 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:
Provider Other Organization Name Type Code:
6
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:
1902464506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2117 LAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHTABULA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44004-3435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-992-4689
Provider Business Mailing Address Fax Number:
440-998-7181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2117 LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHTABULA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44004-3435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-992-4689
Provider Business Practice Location Address Fax Number:
440-998-7181
Provider Enumeration Date:
05/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BLANTON
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
781-699-9000

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)





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