1508837865 NPI number — WYOMING KIDNEY CENTER, LLC

Table of content: (NPI 1508837865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508837865 NPI number — WYOMING KIDNEY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING 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:
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:
1508837865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WORLD TRADE CTR
Provider Second Line Business Mailing Address:
STE 2500
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90831-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-495-8075
Provider Business Mailing Address Fax Number:
562-495-8076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1141 WILKINS CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82601-1332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-472-3700
Provider Business Practice Location Address Fax Number:
307-472-3306
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEINBERG
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
214-736-2700

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  06-046 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114567300 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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