Provider Demographics
NPI:1780058727
Name:ST LOUIS KIDNEY CARE LLC
Entity type:Organization
Organization Name:ST LOUIS KIDNEY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9362
Mailing Address - Street 1:1265 GRAHAM RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8018
Mailing Address - Country:US
Mailing Address - Phone:314-741-1600
Mailing Address - Fax:314-741-1677
Practice Address - Street 1:1265 GRAHAM RD STE 1
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8018
Practice Address - Country:US
Practice Address - Phone:314-741-1600
Practice Address - Fax:314-741-1677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-13
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL455247262-04915-01Medicaid
MO500035811Medicaid