MEDICARE: RENALSOUTH OF LOUISIANA, 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	145	LA

General Provider Information

NPI Number	:	1942209713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENALSOUTH OF LOUISIANA, LLC

Provider Business Mailing Address
First Line	:	2800 MILAN CT
Second Line	:	SUITE 213
City	:	BIRMINGHAM
State	:	AL
Zip	:	35211-6912
Country	:	US
Telephone Number	:	205-943-6700
Fax Number	:	205-943-6697

Provider Business Practice Location Address
First Line	:	397 HIGHWAY 21
Second Line	:	SUITE 602
City	:	MADISONVILLE
State	:	LA
Zip	:	70447-3407
Country	:	US
Telephone Number	:	985-792-5334
Fax Number	:	985-792-5234

Authorized Official
Title or Position	:	CEO
Name	:	MR. TOMMY JAY CARTER
Credential	:
Telephone Number	:	205-943-6700

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	08/22/2020

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