Healthcare Provider Details

I. General information

NPI: 1568560696
Provider Name (Legal Business Name): KIDNEY COUNSELOR,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4163 LOMAC ST
MONTGOMERY AL
36106-2881
US

IV. Provider business mailing address

207 ARROWHEAD DR
MONTGOMERY AL
36117-4105
US

V. Phone/Fax

Practice location:
  • Phone: 334-396-5570
  • Fax: 334-396-5572
Mailing address:
  • Phone: 334-202-4342
  • Fax: 334-277-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number270
License Number StateAL

VIII. Authorized Official

Name: MRS. CECILIA COOK DALTON IX
Title or Position: PRESIDENT/OWNER
Credential: R.D.,L.D.
Phone: 334-202-4342