Provider Demographics
NPI:1285109041
Name:BRANSON KIDNEY CENTER LLC
Entity type:Organization
Organization Name:BRANSON KIDNEY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-334-8288
Mailing Address - Street 1:17829 BUS 13
Mailing Address - Street 2:
Mailing Address - City:BRANSON WEST
Mailing Address - State:MO
Mailing Address - Zip Code:65737-2062
Mailing Address - Country:US
Mailing Address - Phone:417-272-0222
Mailing Address - Fax:417-334-6966
Practice Address - Street 1:17829 BUS 13
Practice Address - Street 2:
Practice Address - City:BRANSON WEST
Practice Address - State:MO
Practice Address - Zip Code:65737-9664
Practice Address - Country:US
Practice Address - Phone:417-334-8288
Practice Address - Fax:417-334-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-09
Last Update Date:2021-09-01
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
26D2157464OtherCLIA CERTIFICATE
MO1285109041Medicaid
AR236152134Medicaid