Basic Information
| Provider Information | |||||||||
| NPI: | 1649675950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | USRC VP HOME, LLC | ||||||||
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| OtherOrganizationName: | U S RENAL CARE VILLA PARK HOME DIALYSIS PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19119 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724036601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709315400 | ||||||||
| FaxNumber: | 8709315418 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 E NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | VILLA PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601811221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304153458 | ||||||||
| FaxNumber: | 6304153463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2014 | ||||||||
| LastUpdateDate: | 10/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | WEIBERG | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER - 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 |
No ID Information.