=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134115124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDNEY DISEASE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2005
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5424 19TH ST # 403
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79407-2162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-368-8782
-----------------------------------------------------
Fax | 806-368-8361
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5424 19TH ST # 403
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79407-2162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-368-8782
-----------------------------------------------------
Fax | 806-368-8361
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | RUBEN DARIO VILLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-368-6391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------