Provider Demographics
NPI:1184141350
Name:KIDNEY CENTER OF TRADITION LLC
Entity type:Organization
Organization Name:KIDNEY CENTER OF TRADITION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF CLINICAL & REGULATORY
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-522-3905
Mailing Address - Street 1:1631 SW GATLIN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4103
Mailing Address - Country:US
Mailing Address - Phone:772-343-7425
Mailing Address - Fax:772-343-7687
Practice Address - Street 1:1631 SW GATLIN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-4103
Practice Address - Country:US
Practice Address - Phone:772-343-7425
Practice Address - Fax:772-343-7687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-28
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment