Healthcare Provider Details

I. General information

NPI: 1932473055
Provider Name (Legal Business Name): KIDNEY DIALYSIS & TRANSPLANT GROUP INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 THOMPSON DR
BRIDGEPORT WV
26330-1644
US

IV. Provider business mailing address

166 THOMPSON DR
BRIDGEPORT WV
26330-1644
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-6001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number20
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number21364
License Number StateWV

VIII. Authorized Official

Name: NABIL GUIRGUIS
Title or Position: PRESIDENT
Credential:
Phone: 304-842-6001