Healthcare Provider Details

I. General information

NPI: 1306499405
Provider Name (Legal Business Name): TRC - FOUR CORNERS DIALYSIS CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 ROWE AVE
FARMINGTON NM
87402-3013
US

IV. Provider business mailing address

5200 VIRGINIA WAY ATT: L&C DEPARTMENT
BRENTWOOD TN
37027
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-9102
  • Fax: 505-326-6633
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 T WEY
Title or Position: VP, LICENSURE & CERTIFICATION
Credential:
Phone: 615-341-6641