Provider Demographics
NPI:1265411300
Name:CHATTANOOGA KIDNEY CENTERS, LLC
Entity type:Organization
Organization Name:CHATTANOOGA KIDNEY CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MANDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:GREWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-648-4900
Mailing Address - Street 1:3810 BRAINERD ROAD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3729
Mailing Address - Country:US
Mailing Address - Phone:423-486-9510
Mailing Address - Fax:923-486-9543
Practice Address - Street 1:2118 STEIN DRIVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1691
Practice Address - Country:US
Practice Address - Phone:423-648-4900
Practice Address - Fax:423-648-4906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000138261QE0700X
TN261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0442651Medicaid
GA003118324AMedicaid
TN0442651Medicaid