1093154916 NPI number — FORT MYERS KIDNEY 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 1093154916 NPI number — FORT MYERS KIDNEY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT MYERS KIDNEY 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:
FORT MYERS KIDNEY CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1093154916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14181 S TAMIAMI TRL
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33912-1939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-415-1062
Provider Business Mailing Address Fax Number:
239-415-1063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14181 S TAMIAMI TRL
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912-1939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-415-1062
Provider Business Practice Location Address Fax Number:
239-415-1063
Provider Enumeration Date:
06/25/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BRADY
Authorized Official First Name:
SARA
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
CHIEF NURSING OFFICER
Authorized Official Telephone Number:
208-371-7878

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: 010564500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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