Healthcare Provider Details

I. General information

NPI: 1831822956
Provider Name (Legal Business Name): KIDNEY CARE HOME SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6125 GREEN BAY RD STE 200
KENOSHA WI
53142-2945
US

IV. Provider business mailing address

6125 GREEN BAY RD STE 200
KENOSHA WI
53142-2945
US

V. Phone/Fax

Practice location:
  • Phone: 262-564-8636
  • Fax: 262-564-8637
Mailing address:
  • Phone: 262-564-8636
  • Fax: 262-564-8637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GANESH N PULLA
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 262-564-8636