=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831856947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDNEY PARTNERS MIAMI BEACH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2021
-----------------------------------------------------
Last Update Date | 11/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4302 ALTON RD STE 760
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33140-2893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-329-2900
-----------------------------------------------------
Fax | 786-534-2079
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 NW 12TH AVE APT 508
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33128-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-329-2900
-----------------------------------------------------
Fax | 786-534-2079
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JUAN MAURICIO CUELLAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 305-329-2900
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------