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General NPI Number Information
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NPI Number | 1801115621
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Entity Type | Organization
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Legal Business Name | KINGSTON DIALYSIS CENTER INC.
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Dates
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Enumeration Date | 05/18/2010
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Last Update Date | 05/18/2010
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Provider Practice Location Address
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Address Line | 1208 N KENTUCKY ST
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City | KINGSTON
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State | TN
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Zip | 37763-2328
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Country | US
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Telephone | 865-248-8006
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Fax |
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Provider Business Mailing Address
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Address Line | 1208 N KENTUCKY ST
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City | KINGSTON
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State | TN
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Zip | 37763-2328
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Country | US
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Telephone | 865-248-8006
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. MOEEN A HATAB
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Credential | PH.D.
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Telephone | 865-850-2900
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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 | 0000000159
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License Number State | TN
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