Provider Demographics
NPI:1598064552
Name:WICHITA FALLS KIDNEY CLINIC PA
Entity Type:Organization
Organization Name:WICHITA FALLS KIDNEY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAYASANKAR
Authorized Official - Middle Name:KALUVAPELLE
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-777-9650
Mailing Address - Street 1:1508 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4401
Mailing Address - Country:US
Mailing Address - Phone:940-263-1286
Mailing Address - Fax:
Practice Address - Street 1:1508 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4401
Practice Address - Country:US
Practice Address - Phone:940-263-1286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty