Provider Demographics
NPI:1922007046
Name:ALEDO KIDNEY CENTER, LLC
Entity Type:Organization
Organization Name:ALEDO KIDNEY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJESH
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-762-5570
Mailing Address - Street 1:400 JOHN DEERE RD
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6898
Mailing Address - Country:US
Mailing Address - Phone:309-762-5570
Mailing Address - Fax:309-762-5297
Practice Address - Street 1:409 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1258
Practice Address - Country:US
Practice Address - Phone:309-582-2227
Practice Address - Fax:309-582-8999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2014-08-29
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
IL50357OtherBCBS OF IL
IL001Medicaid
IL50357OtherBCBS OF IL