MEDICARE: RENAL CARE GROUP NORTHWEST, 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

General Provider Information

NPI Number	:	1548840036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAL CARE GROUP NORTHWEST, INC.

Provider Business Mailing Address
First Line	:	5618 OCEAN BEACH HWY
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-6222
Country	:	US
Telephone Number	:	360-562-4340
Fax Number	:

Provider Business Practice Location Address
First Line	:	5618 OCEAN BEACH HWY
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-6222
Country	:	US
Telephone Number	:	360-562-4340
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	BARRY BLANTON
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	04/09/2021
Last Update Date	:	12/01/2021

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