MEDICARE: KIDNEY HOME, 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	207RN0300X	Nephrology Physician	ME94020	FL

General Provider Information

NPI Number	:	1598191272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY HOME, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1881
Second Line	:
City	:	SANFORD
State	:	FL
Zip	:	32772-1881
Country	:	US
Telephone Number	:	407-323-5047
Fax Number	:	407-323-5048

Provider Business Practice Location Address
First Line	:	2751 ENTERPRISE RD
Second Line	:	SUITE 215
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8256
Country	:	US
Telephone Number	:	407-323-5047
Fax Number	:	407-323-5048

Authorized Official
Title or Position	:	OWNER
Name	:	DAN T TUDOR
Credential	:	MD
Telephone Number	:	407-323-5047

Provider Enumeration Date	:	09/25/2013
Last Update Date	:	09/26/2013

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Directions to “KIDNEY HOME, LLC ” Practice Location

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