MEDICARE: USRC SA HOUSTON STREET, LLC

Medicare Provider Information

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	008134	TX

#	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
3	HH6477	OTHER	TX	BCBS
4	018162	OTHER	TX	KIDNEY HEALTH CARE

NPI Number	:	1164481594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	USRC SA HOUSTON STREET, LLC

Provider Business Mailing Address
First Line	:	PO BOX 19119
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72403-6601
Country	:	US
Telephone Number	:	870-931-5400
Fax Number	:	870-931-5418

Provider Business Practice Location Address
First Line	:	2011 E HOUSTON ST SUITE 102-D
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78202-2912
Country	:	US
Telephone Number	:	210-225-0004
Fax Number	:	210-225-0006

Authorized Official
Title or Position	:	VP, GENERAL COUNSEL
Name	:	THOMAS WEINBERG
Credential	:
Telephone Number	:	214-736-2700

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	01/23/2013

211 CALLE MORSE
ARROYO, PR
00714-2350

Practice Phone: 787-839-3980
Practice Fax: 787-271-2515

227 W DREXEL AVE
SAN ANTONIO, TX
78210-2912