Provider Demographics
NPI:1801420864
Name:THE KIDNEY CARE CENTER, LLC
Entity type:Organization
Organization Name:THE KIDNEY CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHONTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-771-0906
Mailing Address - Street 1:1126 SLIDE RD UNIT 4B
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-5402
Mailing Address - Country:US
Mailing Address - Phone:806-771-0906
Mailing Address - Fax:806-771-0896
Practice Address - Street 1:3702 INTERSTATE 27
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412
Practice Address - Country:US
Practice Address - Phone:806-429-1054
Practice Address - Fax:806-256-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-28
Last Update Date:2022-08-16
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
TX3378366Medicaid