MEDICARE: KIDNEY SPA LLC

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

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	:	1316127921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY SPA LLC

Provider Business Mailing Address
First Line	:	219 NW 12TH AVE
Second Line	:	SUITE C5
City	:	MIAMI
State	:	FL
Zip	:	33128-2205
Country	:	US
Telephone Number	:	305-329-2900
Fax Number	:	305-329-2901

Provider Business Practice Location Address
First Line	:	219 NW 12TH AVE
Second Line	:	UNIT C4
City	:	MIAMI
State	:	FL
Zip	:	33128-2205
Country	:	US
Telephone Number	:	305-329-2900
Fax Number	:	305-329-2901

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. JUAN M CUELLAR
Credential	:	M.D.
Telephone Number	:	305-329-2900

Provider Enumeration Date	:	11/12/2007
Last Update Date	:	10/05/2012

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