Provider Demographics
NPI:1790382513
Name:TRISTATE RENAL CARE LLC
Entity Type:Organization
Organization Name:TRISTATE RENAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYLE
Authorized Official - Middle Name:THI
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-912-7716
Mailing Address - Street 1:6909 BURLINGTON PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1618
Mailing Address - Country:US
Mailing Address - Phone:859-912-7716
Mailing Address - Fax:859-757-4923
Practice Address - Street 1:6909 BURLINGTON PIKE STE B
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1618
Practice Address - Country:US
Practice Address - Phone:859-912-7716
Practice Address - Fax:859-757-4923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment