Healthcare Provider Details

I. General information

NPI: 1669070892
Provider Name (Legal Business Name): KIDNEY WELLCARE & COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9666 OLIVE BLVD STE 205
OLIVETTE MO
63132-3025
US

IV. Provider business mailing address

13439 FORESTLAC DR
SAINT LOUIS MO
63141-6005
US

V. Phone/Fax

Practice location:
  • Phone: 614-425-2604
  • Fax:
Mailing address:
  • Phone: 614-425-2604
  • Fax: 636-216-1987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MR. BARRON E RUTLEDGE
Title or Position: CEO/OWNER
Credential: LCSW
Phone: 614-425-2604