TOTAL RENAL LABORATORIES INC

Provider Demographics

• NPI: 1245720820
• Name: TOTAL RENAL LABORATORIES INC
• Entity type: Organization
• Organization Name: TOTAL RENAL LABORATORIES INC
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: VP - GENERAL MANAGER
• Authorized Official - First Name: KERI
• Authorized Official - Last Name: WAGNER
• Authorized Official - Phone: 386-626-5700
• Mailing Address - Street 1: PO BOX 100244
• Mailing Address - City: ATLANTA
• Mailing Address - State: GA
• Mailing Address - Zip Code: 30384-0244
• Mailing Address - Country: US
• Mailing Address - Phone: 386-626-5700
• Practice Address - Street 1: 3000 DAVITA WAY
• Practice Address - City: DELAND
• Practice Address - State: FL
• Practice Address - Zip Code: 32724
• Practice Address - Country: US
• Practice Address - Phone: 386-626-5700
• Practice Address - Fax: 386-626-5638
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: TOTAL RENAL CARE INC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2018-05-18
• Last Update Date: 2024-08-28

Provider Licenses

State	License ID	Taxonomies
FL	800005025	291U00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	291U00000X	Laboratories	Clinical Medical Laboratory

Provider Identifiers

State	Identifier ID	ID Type	Issuer
PA	0015880660004	Medicaid
OH	0326359	Medicaid
DC	081833728	Medicaid
OK	100758080B	Medicaid
ID	1245720820	Medicaid
NC	1245720820	Medicaid
CA	1245720820	Medicaid
CO	1245720820	Medicaid
UT	3010008	Medicaid
TX	3995045-01	Medicaid
MS	04402709	Medicaid
FL	101245100	Medicaid
MA	110148599A	Medicaid
MN	1245720820	Medicaid
ND	1477612	Medicaid
AL	228520	Medicaid
AR	232372709	Medicaid
IN	300022760	Medicaid
WV	1245720820	Medicaid
WA	2124491	Medicaid
MD	283981402	Medicaid
NH	3118922	Medicaid
OR	500761736	Medicaid
IA	0412083	Medicaid
WY	1245720820	Medicaid
WI	1245720820	Medicaid
NJ	0706493	Medicaid
MI	1245720820	Medicaid
CT	1245720820	Medicaid
VA	1245720820	Medicaid
NM	38436361	Medicaid
KY	7100581410	Medicaid
SC	L00677	Medicaid
TN	Q069472	Medicaid
KS	30003947130002	Medicaid
GA	003214508A	Medicaid
NY	02244535	Medicaid
NE	10026760900	Medicaid
SD	1245720820	Medicaid
LA	2488171	Medicaid
MT	1245720820	Medicaid
ME	1245720820	Medicaid
AZ	504222	Medicaid
MO	700066284	Medicaid