Provider Demographics
NPI:1952400640
Name:AMERI-TECH KIDNEY CENTER
Entity Type:Organization
Organization Name:AMERI-TECH KIDNEY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEIF
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTTORMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-265-7115
Mailing Address - Street 1:1138 S BOWEN RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-2204
Mailing Address - Country:US
Mailing Address - Phone:817-265-7115
Mailing Address - Fax:817-801-7386
Practice Address - Street 1:1600 CENTRAL DR
Practice Address - Street 2:SUITE 130
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6000
Practice Address - Country:US
Practice Address - Phone:817-545-8044
Practice Address - Fax:817-283-0612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000222261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1127359-02Medicaid
TX452655Medicare ID - Type Unspecified