Healthcare Provider Details

I. General information

NPI: 1659334431
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: 09/01/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9836 W 400 N
MICHIGAN CITY IN
46360-2910
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 219-878-1989
  • Fax: 219-878-9569
Mailing address:
  • Phone: 615-320-4514
  • Fax: 866-594-9961

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 T WEY
Title or Position: SR DIRECTOR LICENSURE&CERTIFICATION
Credential:
Phone: 615-341-6641