Provider Demographics
NPI:1952091241
Name:KIDNEYSPA TAMPA BAY HOME LLC
Entity Type:Organization
Organization Name:KIDNEYSPA TAMPA BAY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CUELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-548-4000
Mailing Address - Street 1:219 NW 12TH AVE APT 508
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-2206
Mailing Address - Country:US
Mailing Address - Phone:305-548-4000
Mailing Address - Fax:305-329-2901
Practice Address - Street 1:508 S HABANA AVE STE 270
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4198
Practice Address - Country:US
Practice Address - Phone:305-548-4000
Practice Address - Fax:305-329-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment