MEDICARE: KIDNEYSPA SUGAR LAND HOME LLC

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	:	1821785130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEYSPA SUGAR LAND HOME LLC

Provider Business Mailing Address
First Line	:	PO BOX 352348
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33135-8348
Country	:	US
Telephone Number	:	305-548-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 PROMENADE WAY STE 5
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-7225
Country	:	US
Telephone Number	:	305-548-4000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JUAN M CUELLAR
Credential	:	MD
Telephone Number	:	305-329-2900

Provider Enumeration Date	:	04/18/2023
Last Update Date	:	11/28/2023

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