Provider Demographics
NPI:1750124244
Name:LIFELINE RENAL CARE LLC
Entity type:Organization
Organization Name:LIFELINE RENAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BIJU
Authorized Official - Middle Name:
Authorized Official - Last Name:KURIAKOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-859-9996
Mailing Address - Street 1:2517 SCOTTI ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-5882
Mailing Address - Country:US
Mailing Address - Phone:972-859-9996
Mailing Address - Fax:
Practice Address - Street 1:4309 RIDGECREST RD STE 100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-6003
Practice Address - Country:US
Practice Address - Phone:972-859-9996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment