Provider Demographics
NPI:1659654002
Name:GREENVILLE KIDNEY CARE LLC
Entity Type:Organization
Organization Name:GREENVILLE KIDNEY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-220-1200
Mailing Address - Street 1:10 MEMORIAL MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4450
Mailing Address - Country:US
Mailing Address - Phone:864-220-1200
Mailing Address - Fax:864-220-1888
Practice Address - Street 1:10 MEMORIAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4450
Practice Address - Country:US
Practice Address - Phone:864-220-1200
Practice Address - Fax:864-220-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23113207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5803Medicaid
SCGP5803Medicaid