Healthcare Provider Details

I. General information

NPI: 1912936618
Provider Name (Legal Business Name): KIDNEY LIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 RANDOLPH RD
PLAINFIELD NJ
07060-3361
US

IV. Provider business mailing address

5200 VIRGINIA WAY L&C DEPT
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 908-757-6030
  • Fax: 908-757-6282
Mailing address:
  • Phone: 615-341-6410
  • Fax: 888-662-8259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number23079
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0981648
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: SAMUEL T WEY
Title or Position: VP, LICENSURE & CERTIFICATION
Credential:
Phone: 615-341-6691