Healthcare Provider Details

I. General information

NPI: 1003418997
Provider Name (Legal Business Name): KIDNEY FOCUSED CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2020
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 RIDGEWOOD RD STE 105
JACKSON MS
39216-4962
US

IV. Provider business mailing address

702 PECAN CT
BRANDON MS
39042-6012
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4429
  • Fax: 601-665-4429
Mailing address:
  • Phone: 662-719-9120
  • Fax: 601-665-4429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. JACQUELINE DIANE BOYD
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 601-665-4429