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General NPI Number Information
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NPI Number | 1730250234
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Entity Type | Organization
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Legal Business Name | KANKAKEE VALLEY DIALYSIS NETWORK
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 05/23/2013
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Provider Practice Location Address
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Address Line | 1 E DIVISION ST
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City | MANTENO
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State | IL
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Zip | 60950-1507
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Country | US
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Telephone | 815-468-1000
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Fax | 815-468-7271
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Provider Business Mailing Address
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Address Line | 1 E DIVISION ST
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City | MANTENO
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State | IL
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Zip | 60950-1507
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Country | US
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Telephone | 815-468-1000
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Fax | 815-468-7271
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Authorized Official
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Title or Position | COO
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Name | STACEY A HARSY
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Credential | RN
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Telephone | 815-937-8742
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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 | 000142671
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License Number State | IL
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