Provider Demographics
NPI:1922385558
Name:IROQUOIS KIDNEY CENTER, LLC
Entity Type:Organization
Organization Name:IROQUOIS KIDNEY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HIZON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-937-4422
Mailing Address - Street 1:455 W COURT ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3679
Mailing Address - Country:US
Mailing Address - Phone:815-937-4422
Mailing Address - Fax:
Practice Address - Street 1:209 S 5TH ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1659
Practice Address - Country:US
Practice Address - Phone:815-937-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAPPLIED FOR261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment