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General NPI Number Information
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NPI Number | 1720283302
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Entity Type | Organization
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Legal Business Name | KIDNEY REPLACEMENT THERAPIES, SC
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Dates
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Enumeration Date | 06/15/2007
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Last Update Date | 12/19/2014
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Provider Practice Location Address
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Address Line | 6125 GREEN BAY RD SUITE 100
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City | KENOSHA
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State | WI
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Zip | 53142-2928
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Country | US
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Telephone | 262-564-8636
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Fax | 262-564-8637
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Provider Business Mailing Address
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Address Line | 6125 GREEN BAY RD SUITE 100
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City | KENOSHA
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State | WI
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Zip | 53142-2928
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Country | US
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Telephone | 262-564-8636
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Fax | 262-564-8637
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Authorized Official
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Title or Position | DOCTOR
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Name | GANESH N PULLA
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Credential | MD
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Telephone | 262-564-8636
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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 | 40695-20
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License Number State | WI
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