Provider Demographics
NPI:1700088002
Name:CHILDRENS KIDNEY SPECIALISTS PLLC
Entity Type:Organization
Organization Name:CHILDRENS KIDNEY SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-381-7336
Mailing Address - Street 1:1935 NW NORFOLK CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-8448
Mailing Address - Country:US
Mailing Address - Phone:503-297-3178
Mailing Address - Fax:208-381-7495
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6223
Practice Address - Country:US
Practice Address - Phone:208-381-7336
Practice Address - Fax:208-381-7495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM69432080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010026970OtherBLUE SHIELD
ID003401500Medicaid
ID000010026970OtherBLUE SHIELD
ID003401500Medicaid