Provider Demographics
NPI:1609370279
Name:DENOVA NEPHROLOGY MANAGEMENT LLC
Entity Type:Organization
Organization Name:DENOVA NEPHROLOGY MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-850-8181
Mailing Address - Street 1:PO BOX 5032
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77325-5032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 W OAK ST
Practice Address - Street 2:
Practice Address - City:HIGHLANDS
Practice Address - State:TX
Practice Address - Zip Code:77562-2850
Practice Address - Country:US
Practice Address - Phone:281-850-8181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment