Provider Demographics
NPI:1194069617
Name:RENAL TREATMENT CENTERS-SOUTHEAST, LP.
Entity type:Organization
Organization Name:RENAL TREATMENT CENTERS-SOUTHEAST, LP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP LICENSURE & CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4268
Mailing Address - Fax:877-238-0567
Practice Address - Street 1:204 BRAGG ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-2500
Practice Address - Country:US
Practice Address - Phone:870-226-7180
Practice Address - Fax:870-226-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200362134Medicaid
042576Medicare Oscar/Certification