Basic Information
| Provider Information | |||||||||
| NPI: | 1588849541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RSA - GUAM, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | U.S. RENAL CARE SINAJANA DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 736 ROUTE 4 STE 101 | ||||||||
| Address2: | |||||||||
| City: | SINAJANA | ||||||||
| State: | GU | ||||||||
| PostalCode: | 969103368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6714753600 | ||||||||
| FaxNumber: | 6714772759 | ||||||||
| Practice Location | |||||||||
| Address1: | 736 ROUTE 4 STE 101 | ||||||||
| Address2: | |||||||||
| City: | SINAJANA | ||||||||
| State: | GU | ||||||||
| PostalCode: | 969103368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6714753600 | ||||||||
| FaxNumber: | 6714772759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| LastUpdateDate: | 08/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLANTON | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7816999000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRESENIUS MEDICAL CARE HOLDINGS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/21/2021 | ||||||||
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 | 191 | 05 | GU | MEDICAID |