Provider Demographics
NPI:1134115124
Name:KIDNEY DISEASE ASSOCIATES
Entity Type:Organization
Organization Name:KIDNEY DISEASE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:DARIO
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-368-6391
Mailing Address - Street 1:1607 W LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-5124
Mailing Address - Country:US
Mailing Address - Phone:806-799-2991
Mailing Address - Fax:806-793-5331
Practice Address - Street 1:5424 19TH ST # 403
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2162
Practice Address - Country:US
Practice Address - Phone:806-368-8782
Practice Address - Fax:806-368-8361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1164174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094914101Medicaid