Provider Demographics
NPI:1437330826
Name:KIDNEY CENTER OF LONGMONT LLC
Entity Type:Organization
Organization Name:KIDNEY CENTER OF LONGMONT LLC
Other - Org Name:KIDNEY CENTER OF LONGMONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:1960 KEN PRATT BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6092
Mailing Address - Country:US
Mailing Address - Phone:303-485-7100
Mailing Address - Fax:303-485-7099
Practice Address - Street 1:1960 KEN PRATT BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6092
Practice Address - Country:US
Practice Address - Phone:303-485-7100
Practice Address - Fax:303-485-7099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2023-01-13
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
CO16373545Medicaid
CO16373545Medicaid