=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831388107
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDNEY CENTER OF LAKEWOOD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2007
-----------------------------------------------------
Last Update Date | 01/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6166 W ALAMEDA AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80226-3539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-922-6371
-----------------------------------------------------
Fax | 303-922-6372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6166 W ALAMEDA AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80226-3539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-922-6371
-----------------------------------------------------
Fax | 303-922-6372
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------