Healthcare Provider Details

I. General information

NPI: 1932514387
Provider Name (Legal Business Name): KIDNEY CARE CENTER BLOOMINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 MAIN ST
PEORIA IL
61602-1083
US

IV. Provider business mailing address

PO BOX 3877
JOLIET IL
60434-3877
US

V. Phone/Fax

Practice location:
  • Phone: 309-839-8364
  • Fax: 309-713-1257
Mailing address:
  • Phone: 815-741-6830
  • Fax: 815-741-6832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MORUFU ALAUSA
Title or Position: MEDICAL DIRECTOR/CEO
Credential: M.D.
Phone: 815-741-6830