MEDICARE: TRC - INDIANA 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659334431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRC - INDIANA LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	ATT: L&C DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-320-4514
Fax Number	:	866-594-9961

Provider Business Practice Location Address
First Line	:	9836 W 400 N
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-2910
Country	:	US
Telephone Number	:	219-878-1989
Fax Number	:	219-878-9569

Authorized Official
Title or Position	:	SR DIRECTOR LICENSURE&CERTIFICATION
Name	:	SAMUEL T WEY
Credential	:
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	09/01/2023

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Directions to “TRC - INDIANA LLC ” Practice Location

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