Basic Information
| Provider Information | |||||||||
| NPI: | 1104889849 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENAL TREATMENT CENTERS SOUTHEAST LP | ||||||||
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| OtherOrganizationName: | VALLEY RANCH DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPARTMENT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204514 | ||||||||
| FaxNumber: | 8665949961 | ||||||||
| Practice Location | |||||||||
| Address1: | 22118 MARKETPLACE DR. | ||||||||
| Address2: | 100 | ||||||||
| City: | NEW CANEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773572110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815770006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 000239 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 0942781-05 | 05 | TX | MEDICAID |