Basic Information
| Provider Information | |||||||||
| NPI: | 1427073097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDNEY INSTITUTE OF CLEARWATER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1964 BAYSHORE BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | DUNEDIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346982576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277332040 | ||||||||
| FaxNumber: | 7277330431 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 LAKEVIEW RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274412913 | ||||||||
| FaxNumber: | 7274414291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | JUNE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7277332040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.