Provider Demographics
NPI:1518142710
Name:ISD KANSAS CITY LLC
Entity Type:Organization
Organization Name:ISD KANSAS CITY LLC
Other - Org Name:WESTPORT RENAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR LICENSURE&CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6691
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6264
Mailing Address - Fax:800-297-2925
Practice Address - Street 1:3947 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2516
Practice Address - Country:US
Practice Address - Phone:816-531-1181
Practice Address - Fax:816-531-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2023-08-22
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
MO1518142710Medicaid
MO262631Medicare Oscar/Certification