Provider Demographics
NPI:1316127921
Name:KIDNEY SPA LLC
Entity type:Organization
Organization Name:KIDNEY SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CUELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-329-2900
Mailing Address - Street 1:219 NW 12TH AVE
Mailing Address - Street 2:SUITE C5
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-2205
Mailing Address - Country:US
Mailing Address - Phone:305-329-2900
Mailing Address - Fax:305-329-2901
Practice Address - Street 1:219 NW 12TH AVE
Practice Address - Street 2:UNIT C4
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-2205
Practice Address - Country:US
Practice Address - Phone:305-329-2900
Practice Address - Fax:305-329-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2012-10-05
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
FL10-2872Medicare UPIN