Provider Demographics
NPI:1780228544
Name:NORTHWEST RENAL CLINIC, INC.
Entity Type:Organization
Organization Name:NORTHWEST RENAL CLINIC, INC.
Other - Org Name:ISLAND KIDNEY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / MD
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SMILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-229-7976
Mailing Address - Street 1:1130 NW 22ND AVE STE 640
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5488
Mailing Address - Country:US
Mailing Address - Phone:503-229-7976
Mailing Address - Fax:503-274-4867
Practice Address - Street 1:105 MAUI LANI PKWY STE 100
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2443
Practice Address - Country:US
Practice Address - Phone:808-442-7777
Practice Address - Fax:808-442-7778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST RENAL CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-04
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty