Provider Demographics
NPI:1679828255
Name:KIDNEY CENTER OF MISSIONARY RIDGE, LLC
Entity Type:Organization
Organization Name:KIDNEY CENTER OF MISSIONARY RIDGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-468-1000
Mailing Address - Street 1:3810 BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3729
Mailing Address - Country:US
Mailing Address - Phone:423-486-9510
Mailing Address - Fax:423-486-9512
Practice Address - Street 1:3810 BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-3729
Practice Address - Country:US
Practice Address - Phone:423-486-9510
Practice Address - Fax:423-486-9512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2014-01-17
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
TN442719Medicare Oscar/Certification