Provider Demographics
NPI:1376293621
Name:MY KIDNEY CARE CENTER, LLC
Entity Type:Organization
Organization Name:MY KIDNEY CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANISH
Authorized Official - Middle Name:
Authorized Official - Last Name:PANDYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-278-8575
Mailing Address - Street 1:301 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5619
Mailing Address - Country:US
Mailing Address - Phone:505-278-8575
Mailing Address - Fax:505-787-2399
Practice Address - Street 1:436 VISTA AVE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-1478
Practice Address - Country:US
Practice Address - Phone:928-608-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment