Basic Information
| Provider Information | |||||||||
| NPI: | 1063477727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRC FOUR CORNERS DIALYSIS CLINICS LLC | ||||||||
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| OtherOrganizationName: | FOUR CORNERS DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153416814 | ||||||||
| FaxNumber: | 8002938405 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874015650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053252827 | ||||||||
| FaxNumber: | 5053267425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 6763 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 485137 | 05 | AZ | MEDICAID | 75373 | 05 | NM | MEDICAID |