Provider Demographics
NPI:1720227994
Name:KIDNEY CARE QUAD CITIES, LLC
Entity Type:Organization
Organization Name:KIDNEY CARE QUAD CITIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-756-6880
Mailing Address - Street 1:615 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6107
Mailing Address - Country:US
Mailing Address - Phone:309-757-7783
Mailing Address - Fax:309-757-7719
Practice Address - Street 1:615 35TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6107
Practice Address - Country:US
Practice Address - Phone:309-757-7780
Practice Address - Fax:309-757-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088655207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1720227994OtherNPI
ILIL4229Medicare PIN
ILF79999Medicare UPIN