Provider Demographics
NPI:1336116482
Name:KIDNEY INSTITUTE CENTER OF EXCELLENCE, LLC
Entity Type:Organization
Organization Name:KIDNEY INSTITUTE CENTER OF EXCELLENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-733-2040
Mailing Address - Street 1:1964 BAYSHORE BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-2576
Mailing Address - Country:US
Mailing Address - Phone:727-733-2040
Mailing Address - Fax:
Practice Address - Street 1:601 N 99TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4339
Practice Address - Country:US
Practice Address - Phone:414-755-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2008-05-22
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
WI42061900Medicaid
522566Medicare ID - Type Unspecified