Provider Demographics
NPI:1598212573
Name:WICHITA FALLS KIDNEY DIALYSIS LLC
Entity Type:Organization
Organization Name:WICHITA FALLS KIDNEY DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAYASANKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-716-0557
Mailing Address - Street 1:1508 10TH ST
Mailing Address - Street 2:STE B
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4401
Mailing Address - Country:US
Mailing Address - Phone:940-716-0557
Mailing Address - Fax:940-355-0028
Practice Address - Street 1:1104 HOLLIDAY ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4422
Practice Address - Country:US
Practice Address - Phone:940-716-0557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2020-01-26
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
TX3964322-01Medicaid
HH486YOtherBLUE CROSS BLUE SHIELD