Basic Information
| Provider Information | |||||||||
| NPI: | 1073638144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGIONAL KIDNEY CARE, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KINGSPORT KIDNEY HEALTH, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 BROOKSIDE DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232456000 | ||||||||
| FaxNumber: | 4232456062 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 BROOKSIDE DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232456000 | ||||||||
| FaxNumber: | 4232456062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EARLES | ||||||||
| AuthorizedOfficialFirstName: | MARKALENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4232456000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 021779 | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.