Provider Demographics
NPI:1285630590
Name:WHEELING RENAL CARE LLC
Entity Type:Organization
Organization Name:WHEELING RENAL CARE LLC
Other - Org Name:BELMONT DIALYSIS @ CRESTVIEW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:304-242-7770
Mailing Address - Street 1:500 MEDICAL PARK
Mailing Address - Street 2:STE 100
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-7600
Mailing Address - Country:US
Mailing Address - Phone:304-242-7770
Mailing Address - Fax:304-243-3216
Practice Address - Street 1:68639 BANNOCK RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-9736
Practice Address - Country:US
Practice Address - Phone:740-699-0220
Practice Address - Fax:740-699-0703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0579DC261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459374Medicaid
WV0401005000Medicaid
OH362561Medicare ID - Type Unspecified