Provider Demographics
NPI:1346358538
Name:DIALYSIS & KIDNEY CENTER OF NORTH BREVARD INC
Entity Type:Organization
Organization Name:DIALYSIS & KIDNEY CENTER OF NORTH BREVARD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:321-269-6270
Mailing Address - Street 1:PO BOX 1067
Mailing Address - Street 2:
Mailing Address - City:MIMS
Mailing Address - State:FL
Mailing Address - Zip Code:32754-1067
Mailing Address - Country:US
Mailing Address - Phone:321-269-6270
Mailing Address - Fax:321-383-1625
Practice Address - Street 1:830 CENTURY MEDICAL DR
Practice Address - Street 2:SUITE C
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2149
Practice Address - Country:US
Practice Address - Phone:321-269-6270
Practice Address - Fax:321-383-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL05 0904261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0899219OtherAETNA
FLV4GOtherBLUE SHIELD
FL210743100Medicaid
FL210743100Medicaid