Basic Information
Provider Information | |||||||||
NPI: | 1245208784 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOTAL RENAL CARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMPLETE DIALYSIS CARE SOUTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5200 VIRGINIA WAY | ||||||||
Address2: | STE 400 | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370277569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153204218 | ||||||||
FaxNumber: | 3032097825 | ||||||||
Practice Location | |||||||||
Address1: | 111 SW 23RD ST | ||||||||
Address2: | STE D | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333152516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9548320101 | ||||||||
FaxNumber: | 9548329232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/10/2006 | ||||||||
LastUpdateDate: | 07/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | USILTON | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | O | ||||||||
AuthorizedOfficialTitleorPosition: | GROUP VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7705417922 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.