MEDICARE: RENAL TREATMENT CENTERS-SOUTHEAST, LP.

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	006245	TX

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	:	1487617288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAL TREATMENT CENTERS-SOUTHEAST, LP.

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L&C DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-320-4224
Fax Number	:	800-293-4707

Provider Business Practice Location Address
First Line	:	1809 FOREST RIDGE DR
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76022-7961
Country	:	US
Telephone Number	:	817-545-4509
Fax Number	:	817-545-7392

Authorized Official
Title or Position	:	SR DIRECTOR LICENSURE&CERTIFICATION
Name	:	SAMUEL T WEY
Credential	:
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	09/28/2023

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