Provider Demographics
NPI:1073638144
Name:REGIONAL KIDNEY CARE, PC
Entity Type:Organization
Organization Name:REGIONAL KIDNEY CARE, PC
Other - Org Name:KINGSPORT KIDNEY HEALTH, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARKALENE
Authorized Official - Middle Name:
Authorized Official - Last Name:EARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-245-6000
Mailing Address - Street 1:2002 BROOKSIDE DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4634
Mailing Address - Country:US
Mailing Address - Phone:423-245-6000
Mailing Address - Fax:423-245-6062
Practice Address - Street 1:2002 BROOKSIDE DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4634
Practice Address - Country:US
Practice Address - Phone:423-245-6000
Practice Address - Fax:423-245-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN021779174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05971Medicare ID - Type Unspecified
TN3706367Medicare ID - Type Unspecified