=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265489686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NRA-CROSSVILLE, TENNESSEE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2006
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 DOOLEY ST
-----------------------------------------------------
City | CROSSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38555-4075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-484-4500
-----------------------------------------------------
Fax | 931-484-2130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 DOOLEY ST
-----------------------------------------------------
City | CROSSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38555-4075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-484-4500
-----------------------------------------------------
Fax | 931-484-2130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | BARRY BLANTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-699-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | 0000000148
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------