Provider Demographics
NPI:1548201874
Name:NRA-ST. LOUIS, MISSOURI, LLC
Entity Type:Organization
Organization Name:NRA-ST. LOUIS, MISSOURI, LLC
Other - Org Name:FOREST PARK 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 1:2635 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2912
Mailing Address - Country:US
Mailing Address - Phone:314-646-1717
Mailing Address - Fax:314-646-0636
Practice Address - Street 1:2635 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2912
Practice Address - Country:US
Practice Address - Phone:314-646-1717
Practice Address - Fax:314-646-0636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-09
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MON/A261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506954502Medicaid
MO26D1053303OtherCLIA CERTIFICATE OF WAIVE
MO26-2614Medicare Oscar/Certification