Provider Demographics
NPI:1710947973
Name:TOTAL RENAL CARE OF NORTH CAROLINA LLC
Entity Type:Organization
Organization Name:TOTAL RENAL CARE OF NORTH CAROLINA LLC
Other - Org Name:SOUTHEASTERN DIALYSIS CENTER ELIZABETHTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP LICENSURE & CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4593
Mailing Address - Fax:800-293-5872
Practice Address - Street 1:101 DIALYSIS DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-9048
Practice Address - Country:US
Practice Address - Phone:910-862-7022
Practice Address - Fax:910-862-6312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3412578Medicaid
NC342578Medicare Oscar/Certification
=========032OtherTRICARE