MEDICARE: RENAL CARE GROUP ARIZONA, 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

General Provider Information

NPI Number	:	1588776397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAL CARE GROUP ARIZONA, LLC

Provider Business Mailing Address
First Line	:	2145 MESQUITE AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6913
Country	:	US
Telephone Number	:	928-302-5145
Fax Number	:	928-302-5160

Provider Business Practice Location Address
First Line	:	2145 MESQUITE AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6913
Country	:	US
Telephone Number	:	928-302-5145
Fax Number	:	928-302-5160

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	:	10/23/2023

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