1518233212 NPI number — THE KIDNEY CARE CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518233212 NPI number — THE KIDNEY CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE KIDNEY CARE CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518233212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1126 SLIDE RD
Provider Second Line Business Mailing Address:
SUITE 4B
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79416-5402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-771-0906
Provider Business Mailing Address Fax Number:
806-771-0896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1126 SLIDE RD
Provider Second Line Business Practice Location Address:
SUITE 4B
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79416-5402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-771-0906
Provider Business Practice Location Address Fax Number:
806-771-0896
Provider Enumeration Date:
03/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CARRUTH
Authorized Official First Name:
SHONTAL
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
806-778-9842

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  F7299 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 672714 . This is a "CMS CERTIFICATION NUMBER (CCN)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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