Provider Demographics
NPI:1720072093
Name:RENAL CARE OF WARREN, LLC
Entity Type:Organization
Organization Name:RENAL CARE OF WARREN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALETHEA
Authorized Official - Middle Name:G
Authorized Official - Last Name:CASSIDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-455-6455
Mailing Address - Street 1:1641 SASSAFRAS ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-1858
Mailing Address - Country:US
Mailing Address - Phone:814-455-6455
Mailing Address - Fax:814-456-1188
Practice Address - Street 1:2 W CRESCENT PARK
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2111
Practice Address - Country:US
Practice Address - Phone:814-728-5570
Practice Address - Fax:814-728-5574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1801089Medicaid
392666Medicare ID - Type Unspecified