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NPI Code Detail

MEDICARE: KINGSTON DIALYSIS CENTER INC.

MEDICARE: KINGSTON DIALYSIS CENTER INC.
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
1261QE0700XEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center0000000159TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10000000159OTHERTNSTATE LICENSE

General Provider Information

NPI Number : 1801115621
Entity Type Code : Organization
Provider Name (Legal Business Name) : KINGSTON DIALYSIS CENTER INC.
Provider Business Mailing Address
First Line : 1208 N KENTUCKY ST
Second Line :
City : KINGSTON
State : TN
Zip : 37763-2328
Country : US
Telephone Number : 865-248-8006
Fax Number :
Provider Business Practice Location Address
First Line : 1208 N KENTUCKY ST
Second Line :
City : KINGSTON
State : TN
Zip : 37763-2328
Country : US
Telephone Number : 865-248-8006
Fax Number :
Authorized Official
Title or Position : ADMINISTRATOR
Name : MR. MOEEN A HATAB
Credential : PH.D.
Telephone Number : 865-850-2900
Provider Enumeration Date : 05/18/2010
Last Update Date : 05/18/2010

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