Healthcare Provider Details

I. General information

NPI: 1780058727
Provider Name (Legal Business Name): ST LOUIS KIDNEY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 GRAHAM RD STE 1
FLORISSANT MO
63031-8018
US

IV. Provider business mailing address

1265 GRAHAM RD STE 1
FLORISSANT MO
63031-8018
US

V. Phone/Fax

Practice location:
  • Phone: 314-741-1600
  • Fax: 314-741-1677
Mailing address:
  • Phone: 314-741-1600
  • Fax: 314-741-1677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RYAN VALLE
Title or Position: PRESIDENT
Credential:
Phone: 781-699-9362