Healthcare Provider Details

I. General information

NPI: 1689933772
Provider Name (Legal Business Name): FALL RIVER KIDNEY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 WEAVER ST
FALL RIVER MA
02720-1310
US

IV. Provider business mailing address

48 WEAVER ST
FALL RIVER MA
02720-1310
US

V. Phone/Fax

Practice location:
  • Phone: 508-677-4911
  • Fax: 508-676-5010
Mailing address:
  • Phone: 508-677-4911
  • Fax: 508-676-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110093565A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: SARA ANNE BRADY
Title or Position: CHIEF NURSING OFFICER
Credential:
Phone: 208-371-7878