MEDICARE: RENAL CARE GROUP OF THE SOUTHEAST, INC.

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

General Provider Information

NPI Number	:	1447362280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAL CARE GROUP OF THE SOUTHEAST, INC.

Provider Business Mailing Address
First Line	:	925 MAR WALT DR STE 3
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6609
Country	:	US
Telephone Number	:	850-864-4411
Fax Number	:	850-864-1279

Provider Business Practice Location Address
First Line	:	925 MAR WALT DR STE 3
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6609
Country	:	US
Telephone Number	:	850-864-4411
Fax Number	:	850-864-1279

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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