=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265862619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINCETON KIDNEY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2013
-----------------------------------------------------
Last Update Date | 11/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 FORRESTAL ROAD SOUTH SUITE 100
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-787-5103
-----------------------------------------------------
Fax | 732-641-2043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7475
-----------------------------------------------------
City | MONROE TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08831-7474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-787-5103
-----------------------------------------------------
Fax | 732-641-2043
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KALANIE MENDIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 908-787-5103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 25MA08631100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------