Provider Demographics
NPI:1093154916
Name:FORT MYERS KIDNEY CENTER LLC
Entity Type:Organization
Organization Name:FORT MYERS KIDNEY CENTER LLC
Other - Org Name:FORT MYERS KIDNEY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:14181 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1939
Mailing Address - Country:US
Mailing Address - Phone:239-415-1062
Mailing Address - Fax:239-415-1063
Practice Address - Street 1:14181 S TAMIAMI TRL
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1939
Practice Address - Country:US
Practice Address - Phone:239-415-1062
Practice Address - Fax:239-415-1063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010564500Medicaid
FL010564500Medicaid