Healthcare Provider Details

I. General information

NPI: 1558748459
Provider Name (Legal Business Name): KIDNEY HOUSE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 MARTIN LUTHER KING JR BLVD SUITE C
DALLAS TX
75215-3222
US

IV. Provider business mailing address

1914 SKILLMAN ST SUITE 110-359
DALLAS TX
75206-8559
US

V. Phone/Fax

Practice location:
  • Phone: 214-425-5935
  • Fax: 972-919-0425
Mailing address:
  • Phone: 214-425-5935
  • Fax: 972-919-0425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP125430
License Number StateTX

VIII. Authorized Official

Name: DERRICK LOVE-JONES
Title or Position: CEO
Credential:
Phone: 817-781-2250