Healthcare Provider Details

I. General information

NPI: 1508959172
Provider Name (Legal Business Name): RENAL TREATMENT CENTERS ILLINOIS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 10TH ST STE L100
PERRY IA
50220
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 515-465-2657
  • Fax: 515-465-2874
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

VII. Legacy identifiers

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

# 1
Identifier0625368
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

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