Provider Demographics
NPI:1790845196
Name:SAINT LOUIS RENAL CARE, LLC
Entity Type:Organization
Organization Name:SAINT LOUIS RENAL CARE, LLC
Other - Org Name:ST. LOUIS RENAL CARE - PRINCE HALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:4411 N NEWSTEAD AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4411 N NEWSTEAD AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115
Practice Address - Country:US
Practice Address - Phone:314-381-7696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-08
Last Update Date:2008-10-15
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
MO262598Medicare Oscar/Certification