Basic Information
| Provider Information | |||||||||
| NPI: | 1659672491 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBIA NORTHEAST KIDNEY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7499 PARKLANE RD | ||||||||
| Address2: | SUITE 136 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292237650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038650554 | ||||||||
| FaxNumber: | 8038652816 | ||||||||
| Practice Location | |||||||||
| Address1: | 7499 PARKLANE RD | ||||||||
| Address2: | SUITE 136 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292237650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038650554 | ||||||||
| FaxNumber: | 8038652816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2010 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | GREENE | ||||||||
| AuthorizedOfficialFirstName: | KEISHA | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF CLINICAL & REGULATORY | ||||||||
| AuthorizedOfficialTelephone: | 9785223905 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | RE0026 | 05 | SC | MEDICAID |