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General NPI Number Information
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NPI Number | 1184141350
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Entity Type | Organization
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Legal Business Name | KIDNEY CENTER OF TRADITION LLC
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Dates
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Enumeration Date | 08/28/2017
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Last Update Date | 08/18/2022
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Provider Practice Location Address
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Address Line | 1631 SW GATLIN BLVD SUITE 100
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-4103
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Country | US
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Telephone | 772-343-7425
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Fax | 772-343-7687
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Provider Business Mailing Address
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Address Line | 1631 SW GATLIN BLVD SUITE 100
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-4103
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Country | US
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Telephone | 772-343-7425
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Fax | 772-343-7687
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Authorized Official
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Title or Position | VP OF CLINICAL & REGULATORY
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Name | KEISHA DENISE GREENE
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Credential |
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Telephone | 978-522-3905
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number |
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License Number State |
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