MEDICARE: KIDNEY CARE CENTER OF WINTER HAVEN 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	:	1801496104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY CARE CENTER OF WINTER HAVEN LLC

Provider Business Mailing Address
First Line	:	4960 SW 72ND AVE STE 208
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-5549
Country	:	US
Telephone Number	:	305-448-6261
Fax Number	:

Provider Business Practice Location Address
First Line	:	1107 3RD ST SW STE 9
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33880-3912
Country	:	US
Telephone Number	:	305-448-6261
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. FEDERICO DUMENIGO
Credential	:
Telephone Number	:	305-448-6261

Provider Enumeration Date	:	10/27/2020
Last Update Date	:	12/16/2020

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