Provider Demographics
NPI:1154300564
Name:NRA-PRINCETON, KENTUCKY, LLC
Entity Type:Organization
Organization Name:NRA-PRINCETON, KENTUCKY, LLC
Other - Org Name:CALDWELL COUNTY DIALYSIS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:401 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:KY
Mailing Address - Zip Code:42445-2113
Mailing Address - Country:US
Mailing Address - Phone:270-365-7588
Mailing Address - Fax:270-365-7586
Practice Address - Street 1:401 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-2113
Practice Address - Country:US
Practice Address - Phone:270-365-7588
Practice Address - Fax:270-365-7586
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-13
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300151261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY18D1004814OtherCLIA CERT OF WAIVER
KY39000534Medicaid
KY18-2561Medicare Oscar/Certification