Provider Demographics
NPI:1558748459
Name:KIDNEY HOUSE PLLC
Entity Type:Organization
Organization Name:KIDNEY HOUSE PLLC
Other - Org Name:THE KIDNEY HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVE-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-781-2250
Mailing Address - Street 1:1914 SKILLMAN ST
Mailing Address - Street 2:SUITE 110-359
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-8559
Mailing Address - Country:US
Mailing Address - Phone:214-425-5935
Mailing Address - Fax:972-919-0425
Practice Address - Street 1:1705 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-3222
Practice Address - Country:US
Practice Address - Phone:214-425-5935
Practice Address - Fax:972-919-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125430363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty