Provider Demographics
NPI:1508837865
Name:WYOMING KIDNEY CENTER, LLC
Entity Type:Organization
Organization Name:WYOMING KIDNEY CENTER, LLC
Other - Org Name:U.S. RENAL CARE WYOMING DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
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 1:1 WORLD TRADE CTR
Mailing Address - Street 2:STE 2500
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90831-0002
Mailing Address - Country:US
Mailing Address - Phone:562-495-8075
Mailing Address - Fax:562-495-8076
Practice Address - Street 1:1141 WILKINS CIR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1332
Practice Address - Country:US
Practice Address - Phone:307-472-3700
Practice Address - Fax:307-472-3306
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:U.S. RENAL CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-26
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06-046261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114567300Medicaid
WY532504Medicare Oscar/Certification