Provider Demographics
NPI:1295070811
Name:KIDNEY LIFE, LLC
Entity type:Organization
Organization Name:KIDNEY LIFE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP LICENSURE & CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L & C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 MOUNT PLEASANT AVE
Practice Address - Street 2:STE 340
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2750
Practice Address - Country:US
Practice Address - Phone:973-243-7069
Practice Address - Fax:973-731-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2025-03-11
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
NJ0968676Medicaid