MEDICARE: RENAL CENTER OF KELLER, 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

General Provider Information

NPI Number	:	1770915217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAL CENTER OF KELLER, LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L&C DEPARTMENT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10708 VICTORIA ASH DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-6392
Country	:	US
Telephone Number	:	817-431-6533
Fax Number	:	817-431-6543

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

Provider Enumeration Date	:	08/07/2013
Last Update Date	:	10/03/2024

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