Provider Demographics
NPI:1669658472
Name:OKLAHOMA KIDNEY CARE DIALYSIS, LLC
Entity Type:Organization
Organization Name:OKLAHOMA KIDNEY CARE DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-748-5800
Mailing Address - Street 1:13901 MCAULEY BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-8700
Mailing Address - Country:US
Mailing Address - Phone:405-748-5812
Mailing Address - Fax:405-748-5818
Practice Address - Street 1:13901 MCAULEY BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-8700
Practice Address - Country:US
Practice Address - Phone:405-748-5800
Practice Address - Fax:405-748-5806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment