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General NPI Number Information
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NPI Number | 1922385558
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Entity Type | Organization
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Legal Business Name | IROQUOIS KIDNEY CENTER, LLC
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Dates
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Enumeration Date | 11/10/2011
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Last Update Date | 11/10/2011
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Provider Practice Location Address
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Address Line | 209 S 5TH ST
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City | WATSEKA
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State | IL
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Zip | 60970-1659
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Country | US
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Telephone | 815-937-4422
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Fax |
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Provider Business Mailing Address
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Address Line | 455 W COURT ST SUITE 304
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City | KANKAKEE
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State | IL
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Zip | 60901-3679
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Country | US
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Telephone | 815-937-4422
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MIGUEL HIZON
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Credential | MD
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Telephone | 815-937-4422
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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 | APPLIED FOR
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License Number State | IL
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