Provider Demographics
NPI:1881276665
Name:RENAL RD WV LLC
Entity type:Organization
Organization Name:RENAL RD WV LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATE
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD CSR LD
Authorized Official - Phone:304-617-4067
Mailing Address - Street 1:1811 COFFMAN ST
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-2023
Mailing Address - Country:US
Mailing Address - Phone:304-617-4067
Mailing Address - Fax:
Practice Address - Street 1:1811 COFFMAN ST
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-2023
Practice Address - Country:US
Practice Address - Phone:304-617-4067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty