Healthcare Provider Details

I. General information

NPI: 1265767628
Provider Name (Legal Business Name): TOTAL RENAL CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 07/22/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 PROGRESS RD
HANNIBAL MO
63401-6628
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 573-406-0165
  • Fax: 573-406-0144
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

VII. Legacy identifiers

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

# 1
Identifier=========
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier1265767628
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: SAMUEL T WEY
Title or Position: VP LICENSURE & CERTIFICATION
Credential:
Phone: 615-341-6641