Basic Information
| Provider Information | |||||||||
| NPI: | 1720072093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENAL CARE OF WARREN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1641 SASSAFRAS ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165021858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144556455 | ||||||||
| FaxNumber: | 8144561188 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 W CRESCENT PARK | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147285570 | ||||||||
| FaxNumber: | 8147285574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CASSIDY | ||||||||
| AuthorizedOfficialFirstName: | ALETHEA | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8144556455 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1801089 | 05 | PA | MEDICAID |