Basic Information
Provider Information | |||||||||
NPI: | 1003280066 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEW ORLEANS KIDNEY CARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3820 W HAPPY VALLEY RD | ||||||||
Address2: | SUITE 141-120 | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853103289 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8445408736 | ||||||||
FaxNumber: | 6027988267 | ||||||||
Practice Location | |||||||||
Address1: | 920 WINTER ST | ||||||||
Address2: |   | ||||||||
City: | WALTHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 024511521 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8445408736 | ||||||||
FaxNumber: | 6027988267 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2015 | ||||||||
LastUpdateDate: | 11/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | PAMELA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CORPORATE VP | ||||||||
AuthorizedOfficialTelephone: | 4806397185 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.