Healthcare Provider Details

I. General information

NPI: 1841051786
Provider Name (Legal Business Name): RENAL SERVICES OF AMERICA MANGILAO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N ROUTE 10
MANGILAO GU
96913-6065
US

IV. Provider business mailing address

220 N ROUTE 10
MANGILAO GU
96913-6065
US

V. Phone/Fax

Practice location:
  • Phone: 671-777-6535
  • Fax:
Mailing address:
  • Phone: 671-777-6535
  • Fax:

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: BARRY BLANTON
Title or Position: VP
Credential:
Phone: 781-699-9000