MEDICARE: WHEELING RENAL CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073519369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHEELING RENAL CARE LLC

Provider Business Mailing Address
First Line	:	500 MEDICAL PARK
Second Line	:	STE 100
City	:	WHEELING
State	:	WV
Zip	:	26003-7600
Country	:	US
Telephone Number	:	304-242-7770
Fax Number	:	304-243-3216

Provider Business Practice Location Address
First Line	:	1 BENJAMIN DR
Second Line	:
City	:	NEW MARTINSVILLE
State	:	WV
Zip	:	26155
Country	:	US
Telephone Number	:	304-455-2700
Fax Number	:	304-455-4151

Authorized Official
Title or Position	:	ASSISTANT ADMINISTRATOR
Name	:	MRS. DEBRA LUCKI
Credential	:	R.N.
Telephone Number	:	304-242-7770

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	08/22/2020

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Directions to “WHEELING RENAL CARE LLC ” Practice Location

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