MEDICARE: USRC KELLER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1073959631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	USRC KELLER LLC

Provider Business Mailing Address
First Line	:	PO BOX 844631
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4631
Country	:	US
Telephone Number	:	870-931-5400
Fax Number	:	870-931-5400

Provider Business Practice Location Address
First Line	:	4420 HERITAGE TRACE PKWY
Second Line	:	SUITE 312
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8904
Country	:	US
Telephone Number	:	817-993-6516
Fax Number	:	817-562-4467

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	THOMAS L. WEINBERG
Credential	:
Telephone Number	:	214-736-2700

Provider Enumeration Date	:	05/22/2013
Last Update Date	:	05/25/2022

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