Healthcare Provider Details

I. General information

NPI: 1689209157
Provider Name (Legal Business Name): KIDNEY AND PRIMARY CARE OF TEXAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 MEDICAL DR STE 110
SAN ANTONIO TX
78229-2292
US

IV. Provider business mailing address

3939 MEDICAL DR STE 110
SAN ANTONIO TX
78229-2292
US

V. Phone/Fax

Practice location:
  • Phone: 210-858-7604
  • Fax: 210-888-0383
Mailing address:
  • Phone: 210-858-7604
  • Fax: 210-888-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SRINATH TAMIRISA
Title or Position: OWNER
Credential: MD
Phone: 916-947-6491