Basic Information
| Provider Information | |||||||||
| NPI: | 1669459079 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | USRC SAN BENITO DIALYSIS LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | US RENAL CARE SAN BENITO DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 251549 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750251500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709315400 | ||||||||
| FaxNumber: | 8709315418 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 N MCCULLOUGH ST | ||||||||
| Address2: | |||||||||
| City: | SAN BENITO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785860084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563994037 | ||||||||
| FaxNumber: | 9563998119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | WEINBERG | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE-PRESIDENT/GENERAL COUNS | ||||||||
| AuthorizedOfficialTelephone: | 2147362700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | US RENAL CARE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 008215 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 176515802 | 05 | TX | MEDICAID | HH043Y | 01 | TX | BCBS | OTHER | 018885 | 01 | TX | KIDNEY HEALTH CARE | OTHER | 176515801 | 05 | TX | MEDICAID |