Provider Demographics
NPI:1760665129
Name:THE KIDNEY CLINIC LLC
Entity Type:Organization
Organization Name:THE KIDNEY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDEL
Authorized Official - Middle Name:FARID
Authorized Official - Last Name:ABU SHAMAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-494-7090
Mailing Address - Street 1:PO BOX 3230
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-3230
Mailing Address - Country:US
Mailing Address - Phone:337-494-7090
Mailing Address - Fax:337-494-7040
Practice Address - Street 1:333 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:SUITE 140
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5887
Practice Address - Country:US
Practice Address - Phone:337-494-7090
Practice Address - Fax:337-494-7040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD11617R261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1679232Medicaid
LA1679232Medicaid
5DC 09Medicare PIN