MEDICARE: KIDNEY LIFE INCORPORATED

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
2	V19	OTHER	FL	BCBS FL

General Provider Information

NPI Number	:	1760523294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY LIFE INCORPORATED

Provider Business Mailing Address
First Line	:	PO BOX 47069
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33743-7069
Country	:	US
Telephone Number	:	727-589-6550
Fax Number	:	727-898-5317

Provider Business Practice Location Address
First Line	:	10755 PARK BLVD
Second Line	:	SUITE B
City	:	SEMINOLE
State	:	FL
Zip	:	33772-5420
Country	:	US
Telephone Number	:	727-393-5551
Fax Number	:	727-398-1971

Authorized Official
Title or Position	:	CEO PRESIDENT
Name	:	MS. JOSSETTE S MALTI
Credential	:	RN
Telephone Number	:	727-896-5500

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	04/23/2012

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Directions to “KIDNEY LIFE INCORPORATED ” Practice Location

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