Provider Demographics
NPI:1881675239
Name:ATLANTIC KIDNEY CENTERS INC
Entity Type:Organization
Organization Name:ATLANTIC KIDNEY CENTERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-845-2888
Mailing Address - Street 1:4700 N CONGRESS AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3282
Mailing Address - Country:US
Mailing Address - Phone:561-845-2888
Mailing Address - Fax:561-845-7282
Practice Address - Street 1:4700 N CONGRESS AVE
Practice Address - Street 2:STE 104
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3282
Practice Address - Country:US
Practice Address - Phone:561-845-2888
Practice Address - Fax:561-845-7282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
209348OtherAMERIGROUP
FL21209330Medicaid
V7QOtherBCBS OF FL
FL21209330Medicaid