MEDICARE: LAKE JACKSON DIALYSIS AND KIDNEY CENTER, LTD, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	008101	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215961545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE JACKSON DIALYSIS AND KIDNEY CENTER, LTD, LLP

Provider Business Mailing Address
First Line	:	PO BOX 4639
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77210-4639
Country	:	US
Telephone Number	:	979-864-4330
Fax Number	:	979-864-3560

Provider Business Practice Location Address
First Line	:	450 THIS WAY ST STE A
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5152
Country	:	US
Telephone Number	:	979-299-6565
Fax Number	:	979-299-6568

Authorized Official
Title or Position	:	BUSINESS ADMINISTRATOR
Name	:	MR. MICHAEL JAEGER
Credential	:
Telephone Number	:	713-774-4000

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	08/10/2009

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