1164920567 NPI number — KIDNEY CENTER HOME THERAPIES LLC

Table of content: YWA DU MOO (NPI 1306727326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164920567 NPI number — KIDNEY CENTER HOME THERAPIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDNEY CENTER HOME THERAPIES 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:
1164920567
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4822 MARKET ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOARDMAN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44512-2122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-781-6212
Provider Business Mailing Address Fax Number:
330-953-2041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 GRAMPIAN BLVD STE 1B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSPORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17701-1965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-478-5228
Provider Business Practice Location Address Fax Number:
570-601-4020
Provider Enumeration Date:
01/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
AMEDIA
Authorized Official First Name:
CHESTER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
330-781-6212

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)





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