Healthcare Provider Details

I. General information

NPI: 1184680803
Provider Name (Legal Business Name): TRC - FOUR CORNERS DIALYSIS CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HIGHWAY 191
CHINLE AZ
86503
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 928-674-5426
  • Fax: 928-674-5461
Mailing address:
  • Phone: 615-341-6814
  • Fax: 800-293-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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