Healthcare Provider Details

I. General information

NPI: 1336116482
Provider Name (Legal Business Name): KIDNEY INSTITUTE CENTER OF EXCELLENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 99TH ST SUITE 100
WAUWATOSA WI
53226-4339
US

IV. Provider business mailing address

1964 BAYSHORE BLVD STE C
DUNEDIN FL
34698-2576
US

V. Phone/Fax

Practice location:
  • Phone: 414-755-6300
  • Fax:
Mailing address:
  • Phone: 727-733-2040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JUNE A. CLARK
Title or Position: BUSINESS MANAGER
Credential:
Phone: 727-733-2040