Healthcare Provider Details

I. General information

NPI: 1487619326
Provider Name (Legal Business Name): TRC - FOUR CORNERS DIALYSIS CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HIGHWAY 491 NORTH
SHIPROCK NM
87420-2156
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-368-4125
  • Fax: 505-368-4235
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 Number6762
License Number StateNM

VIII. Authorized Official

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