Healthcare Provider Details

I. General information

NPI: 1790740793
Provider Name (Legal Business Name): RENAL TREATMENT CENTERS-SOUTHEAST, LP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 11/25/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 E CRAIG ST
ATMORE AL
36502
US

IV. Provider business mailing address

5200 VIRGINIA WAY ATT: L&C DEPT
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 251-368-5593
  • Fax: 251-446-1950
Mailing address:
  • Phone: 615-320-4268
  • Fax: 877-238-0567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberS2703
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1790740793
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name: JOHN D. WINSTEL
Title or Position: CHIEF ACCOUNTING OFFICER
Credential:
Phone: 253-733-4501