Provider Demographics
NPI:1487210316
Name:KIDNEY CARE CENTER GWINNETT LLC
Entity Type:Organization
Organization Name:KIDNEY CARE CENTER GWINNETT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MORUFU
Authorized Official - Middle Name:OLATUNJI
Authorized Official - Last Name:ALAUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-741-6830
Mailing Address - Street 1:PO BOX 3877
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60434-3877
Mailing Address - Country:US
Mailing Address - Phone:815-741-6830
Mailing Address - Fax:815-941-1806
Practice Address - Street 1:601A PROFESSIONAL DR STE 235
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7697
Practice Address - Country:US
Practice Address - Phone:470-292-3957
Practice Address - Fax:470-292-3683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-16
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty