Provider Demographics
NPI:1861681132
Name:KIDNEY CENTER OF LAFAYETTE LLC
Entity Type:Organization
Organization Name:KIDNEY CENTER OF LAFAYETTE LLC
Other - Org Name:KIDNEY CENTER OF LAFAYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:2655 CRESCENT DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3373
Mailing Address - Country:US
Mailing Address - Phone:720-890-4661
Mailing Address - Fax:720-890-4662
Practice Address - Street 1:2655 CRESCENT DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3373
Practice Address - Country:US
Practice Address - Phone:720-890-4661
Practice Address - Fax:720-890-4662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2023-01-10
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
CO24657859Medicaid
CO24657859Medicaid