Provider Demographics
NPI:1215959184
Name:UNIVERSAL KIDNEY CENTER OF PEMBROKE PINES-MIRAMAR LLC
Entity type:Organization
Organization Name:UNIVERSAL KIDNEY CENTER OF PEMBROKE PINES-MIRAMAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ELMO ANGELO
Authorized Official - Middle Name:V
Authorized Official - Last Name:BARTOLOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-770-6540
Mailing Address - Street 1:18004 NW 6TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2823
Mailing Address - Country:US
Mailing Address - Phone:954-433-9400
Mailing Address - Fax:
Practice Address - Street 1:18004 NW 6TH ST STE 101
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2823
Practice Address - Country:US
Practice Address - Phone:954-433-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102841Medicare Oscar/Certification