Organization
RENAL TREATMENT CENTERS-SOUTHEAST, LP
Active
Other names
Lake Jackson Dialysis
Organization subpart
No
Provider details
NPI number
Authorized official
SAMUEL T WEY (VP LICENSURE&CERTIFICATION)
(615) 341-6641
Entity
Organization
Contact information
Practice address
450 THIS WAY ST, STE A, LAKE JACKSON, TX 77566-5152
(979) 299-6565
(979) 299-6568
Mailing address
5200 VIRGINIA WAY, L&C DEPARTMENT, BRENTWOOD, TN 37027-7569
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
110303
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3454654-01
MEDICAID
TX
Enumeration date
07/22/2014
Last updated
04/22/2024
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