Basic Information
| Provider Information | |||||||||
| NPI: | 1083660617 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EL PASO KIDNEY CENTER EAST LTD | ||||||||
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| OtherOrganizationName: | U.S. RENAL CARE EAST EL PASO DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 424 CHURCH ST | ||||||||
| Address2: | SUITE 1900 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372192301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152341188 | ||||||||
| FaxNumber: | 6152349526 | ||||||||
| Practice Location | |||||||||
| Address1: | 10737 GATEWAY BLVD W | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799354920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155908334 | ||||||||
| FaxNumber: | 9155909051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | WEINBERG | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2147362700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | U.S. RENAL CARE, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 1910234-02 | 05 | TX | MEDICAID |