Provider Demographics
NPI:1437573995
Name:LEWIS CLARK KIDNEY CENTER LLC
Entity Type:Organization
Organization Name:LEWIS CLARK KIDNEY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AJITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-743-9986
Mailing Address - Street 1:1835 G ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2034
Mailing Address - Country:US
Mailing Address - Phone:208-743-9986
Mailing Address - Fax:208-743-1318
Practice Address - Street 1:222 SOUTHWAY AVE STE A
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2703
Practice Address - Country:US
Practice Address - Phone:208-743-9986
Practice Address - Fax:208-743-1318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment