Healthcare Provider Details

I. General information

NPI: 1265489686
Provider Name (Legal Business Name): NRA-CROSSVILLE, TENNESSEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DOOLEY ST
CROSSVILLE TN
38555-4075
US

IV. Provider business mailing address

121 DOOLEY ST
CROSSVILLE TN
38555-4075
US

V. Phone/Fax

Practice location:
  • Phone: 931-484-4500
  • Fax: 931-484-2130
Mailing address:
  • Phone: 931-484-4500
  • Fax: 931-484-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number0000000148
License Number StateTN

VIII. Authorized Official

Name: BARRY BLANTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 781-699-9000