Provider Demographics
NPI:1689715112
Name:KIDNEY LIFE, INC.
Entity Type:Organization
Organization Name:KIDNEY LIFE, INC.
Other - Org Name:THE BAYS DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JOSSETTE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MALTI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:727-896-5500
Mailing Address - Street 1:PO BOX 47069
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33743-7069
Mailing Address - Country:US
Mailing Address - Phone:727-896-5500
Mailing Address - Fax:727-898-5317
Practice Address - Street 1:446 4TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4603
Practice Address - Country:US
Practice Address - Phone:727-896-5500
Practice Address - Fax:727-898-5317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2016-02-15
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
FL208942400Medicaid
FL208942400Medicaid