Healthcare Provider Details

I. General information

NPI: 1699893610
Provider Name (Legal Business Name): SAN ANTONIO KIDNEY DISEASE CENTER PHYSICIANS GROUP, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 MENGER SPGS SUITE 1210
BOERNE TX
78006-7218
US

IV. Provider business mailing address

7142 SAN PEDRO AVE STE 120
SAN ANTONIO TX
78216-6256
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-8280
  • Fax: 210-481-3116
Mailing address:
  • Phone: 210-481-7453
  • Fax: 210-481-7463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CLAY ROBY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 210-481-7453