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General NPI Number Information
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NPI Number | 1598191272
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Entity Type | Organization
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Legal Business Name | KIDNEY HOME, LLC
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Dates
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Enumeration Date | 09/25/2013
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Last Update Date | 09/26/2013
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Provider Practice Location Address
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Address Line | 2751 ENTERPRISE RD SUITE 215
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City | ORANGE CITY
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State | FL
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Zip | 32763-8256
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Country | US
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Telephone | 407-323-5047
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Fax | 407-323-5048
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Provider Business Mailing Address
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Address Line | PO BOX 1881
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City | SANFORD
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State | FL
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Zip | 32772-1881
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Country | US
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Telephone | 407-323-5047
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Fax | 407-323-5048
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Authorized Official
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Title or Position | OWNER
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Name | DAN T TUDOR
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Credential | MD
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Telephone | 407-323-5047
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | ME94020
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License Number State | FL
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