1154777068 NPI number — NORTH TEXAS KIDNEY DISEASE ASSOCIATES

Table of content: (NPI 1154777068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154777068 NPI number — NORTH TEXAS KIDNEY DISEASE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH TEXAS KIDNEY DISEASE ASSOCIATES
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:
1154777068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 WATERS RIDGE DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75057-6039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-219-0558
Provider Business Mailing Address Fax Number:
214-466-7237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4333 N JOSEY LN STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75010-4620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-219-0558
Provider Business Practice Location Address Fax Number:
972-436-9273
Provider Enumeration Date:
05/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
SIRENA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
214-466-7230

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 146883702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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