MEDICARE: RELIANT RENAL CARE-TEXAS, 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	45-2563	OTHER	TX	PTAN

General Provider Information

NPI Number	:	1386689891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RELIANT RENAL CARE-TEXAS, LLC

Provider Business Mailing Address
First Line	:	1032 SANDY LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-3314
Country	:	US
Telephone Number	:	817-429-1944
Fax Number	:	817-457-6873

Provider Business Practice Location Address
First Line	:	1032 SANDY LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-3314
Country	:	US
Telephone Number	:	817-429-1944
Fax Number	:	817-457-6873

Authorized Official
Title or Position	:	SVP AND TREASURER
Name	:	MARK FAWCETT
Credential	:
Telephone Number	:	781-699-2668

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	03/19/2018

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