MEDICARE: BRAZORIA KIDNEY CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1437261310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAZORIA KIDNEY CENTER, INC.

Provider Business Mailing Address
First Line	:	405 THIS WAY ST
Second Line	:	SUITE 3
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5140
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 THIS WAY ST
Second Line	:	SUITE 3
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5140
Country	:	US
Telephone Number	:	979-299-1936
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	MARK FAWCETT
Credential	:
Telephone Number	:	781-402-9000

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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