MEDICARE: INLAND NORTHWEST RENAL CARE GROUP, 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	502535	OTHER	WA	PTAN

General Provider Information

NPI Number	:	1154433050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INLAND NORTHWEST RENAL CARE GROUP, LLC

Provider Business Mailing Address
First Line	:	800 JASMINE ST STE 1
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9501
Country	:	US
Telephone Number	:	509-826-8680
Fax Number	:	509-826-8690

Provider Business Practice Location Address
First Line	:	800 JASMINE ST STE 1
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9501
Country	:	US
Telephone Number	:	509-826-8680
Fax Number	:	509-826-8690

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	BARRY L. BLANTON
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	10/16/2023

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