Healthcare Provider Details

I. General information

NPI: 1720283302
Provider Name (Legal Business Name): KIDNEY REPLACEMENT THERAPIES, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6125 GREEN BAY RD SUITE 100
KENOSHA WI
53142-2928
US

IV. Provider business mailing address

6125 GREEN BAY RD SUITE 100
KENOSHA WI
53142-2928
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 Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number40695-20
License Number StateWI

VIII. Authorized Official

Name: GANESH N PULLA
Title or Position: DOCTOR
Credential: MD
Phone: 262-564-8636