Basic Information
| Provider Information | |||||||||
| NPI: | 1972056893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVO KIDNEY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 WINTER ST | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806397186 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 WINTER ST | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806397186 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2016 | ||||||||
| LastUpdateDate: | 07/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | VP | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4806397186 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 001 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.