Basic Information
| Provider Information | |||||||||
| NPI: | 1417948340 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RENAL CARE CONSULTANTS PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REDWOOD DIALYSIS SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 SW L ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975262913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414740776 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2868 CREEKSIDE CIR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417764805 | ||||||||
| FaxNumber: | 5417736016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCEWEN | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5417764805 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2472R0900X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Technician, Other | Renal Dialysis |
ID Information
| ID | Type | State | Issuer | Description | XCDC00694 | 01 | CA | MEDI CAL | OTHER | 208391 | 05 | OR | MEDICAID |