Provider Demographics
NPI:1407525447
Name:PONDEROSA PINE, LLC
Entity Type:Organization
Organization Name:PONDEROSA PINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-736-2700
Mailing Address - Street 1:PO BOX 251549
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-1500
Mailing Address - Country:US
Mailing Address - Phone:214-736-2700
Mailing Address - Fax:
Practice Address - Street 1:9777 S YOSEMITE ST STE 130AB&C
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-3191
Practice Address - Country:US
Practice Address - Phone:720-798-3714
Practice Address - Fax:720-798-3755
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:U.S. RENAL CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment