Healthcare Provider Details

I. General information

NPI: 1134588957
Provider Name (Legal Business Name): ST GEORGE KIDNEY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 S 1000 E STE 103
ST GEORGE UT
84790-5902
US

IV. Provider business mailing address

624 S 1000 E STE 103
ST GEORGE UT
84790-5902
US

V. Phone/Fax

Practice location:
  • Phone: 435-652-1135
  • Fax: 435-652-1190
Mailing address:
  • Phone: 435-652-1135
  • Fax: 435-652-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier3001772
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: RYAN VALLE
Title or Position: PRESIDENT
Credential:
Phone: 781-699-9362