=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437330826
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDNEY CENTER OF LONGMONT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2007
-----------------------------------------------------
Last Update Date | 01/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1960 KEN PRATT BLVD SUITE A
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-6092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-485-7100
-----------------------------------------------------
Fax | 303-485-7099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1960 KEN PRATT BLVD SUITE A
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-6092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-485-7100
-----------------------------------------------------
Fax | 303-485-7099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF NURSING OFFICER
-----------------------------------------------------
Name | SARA ANNE BRADY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-371-7878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------