Healthcare Provider Details

I. General information

NPI: 1578526216
Provider Name (Legal Business Name): TRC - INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 FIR ST UNIT 404
EAST CHICAGO IN
46312-3078
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 219-397-1199
  • Fax: 219-397-1625
Mailing address:
  • Phone:
  • 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: SAMUEL WEY
Title or Position: VP LICENSURE & CERTIFICATION
Credential:
Phone: 615-341-6641