MEDICARE: RELIANT RENAL CARE LAPEER HOME CHOICE 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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	K8938	OTHER	MI	BCBS PRIMARY
3	K9438	OTHER	MI	BCBS SECONDARY

General Provider Information

NPI Number	:	1548691496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RELIANT RENAL CARE LAPEER HOME CHOICE LLC

Provider Business Mailing Address
First Line	:	582 S MAIN ST
Second Line	:
City	:	LAPEER
State	:	MI
Zip	:	48446-2467
Country	:	US
Telephone Number	:	810-969-4188
Fax Number	:	810-969-4191

Provider Business Practice Location Address
First Line	:	582 S MAIN ST
Second Line	:
City	:	LAPEER
State	:	MI
Zip	:	48446-2467
Country	:	US
Telephone Number	:	810-969-4188
Fax Number	:	810-969-4191

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

Provider Enumeration Date	:	12/03/2013
Last Update Date	:	10/20/2023

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