=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043457484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENAL TREATMENT CENTERS SOUTHEAST LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2009
-----------------------------------------------------
Last Update Date | 05/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5036 TENNYSON PKWY
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-608-1089
-----------------------------------------------------
Fax | 972-608-1096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L&C DEPT 4TH FLOOR
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-320-4550
-----------------------------------------------------
Fax | 866-500-8578
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ACCOUNTING OFFICER
-----------------------------------------------------
Name | JAMES K HILGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-382-1919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | 110009
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------