Provider Demographics
NPI:1265862619
Name:PRINCETON KIDNEY CARE LLC
Entity Type:Organization
Organization Name:PRINCETON KIDNEY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-787-5103
Mailing Address - Street 1:PO BOX 7475
Mailing Address - Street 2:
Mailing Address - City:MONROE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-7474
Mailing Address - Country:US
Mailing Address - Phone:908-787-5103
Mailing Address - Fax:732-641-2043
Practice Address - Street 1:10 FORRESTAL ROAD SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540
Practice Address - Country:US
Practice Address - Phone:908-787-5103
Practice Address - Fax:732-641-2043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08631100207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0215821Medicaid