Provider Demographics
NPI:1477212959
Name:KIDNEYSPA IN-HOME DIALYSIS SE TEXAS LLC
Entity Type:Organization
Organization Name:KIDNEYSPA IN-HOME DIALYSIS SE TEXAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CUELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-329-2900
Mailing Address - Street 1:219 NW 12TH AVE APT 508
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-2206
Mailing Address - Country:US
Mailing Address - Phone:305-329-2900
Mailing Address - Fax:
Practice Address - Street 1:7102 BROOKSIDE RD
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-7323
Practice Address - Country:US
Practice Address - Phone:832-352-4277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-13
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies