1043610819 NPI number — THE KIDNEY CARE CENTER, LLC

Table of content: (NPI 1043610819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043610819 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:
6
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:
1043610819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2022
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:
3921 N. CALLE GRANDE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBBS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88240-0954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-738-0400
Provider Business Practice Location Address Fax Number:
575-738-0402
Provider Enumeration Date:
08/29/2014

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:
806-771-0906

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3538 . This is a "NEW MEXICO DEPARTMENT OF HEALTH" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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