Provider Demographics
NPI:1518233212
Name:THE KIDNEY CARE CENTER, LLC
Entity Type:Organization
Organization Name:THE KIDNEY CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHONTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-778-9842
Mailing Address - Street 1:1126 SLIDE RD
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-5402
Mailing Address - Country:US
Mailing Address - Phone:806-771-0906
Mailing Address - Fax:806-771-0896
Practice Address - Street 1:1126 SLIDE RD
Practice Address - Street 2:SUITE 4B
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-5402
Practice Address - Country:US
Practice Address - Phone:806-771-0906
Practice Address - Fax:806-771-0896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7299261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX672714OtherCMS CERTIFICATION NUMBER (CCN)