Provider Demographics
NPI:1316958663
Name:LUBBOCK KIDNEY & BLOOD PRESSURE CLINIC P A
Entity type:Organization
Organization Name:LUBBOCK KIDNEY & BLOOD PRESSURE CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:806-793-8447
Mailing Address - Street 1:1126 SLIDE RD
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-5402
Mailing Address - Country:US
Mailing Address - Phone:806-793-8447
Mailing Address - Fax:
Practice Address - Street 1:1126 SLIDE RD
Practice Address - Street 2:SUITE 4B
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-5402
Practice Address - Country:US
Practice Address - Phone:806-793-8447
Practice Address - Fax:806-793-0498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG-8915Medicaid
TX00DG98OtherBLUECROSS BLUESHIELD
TXC12381OtherPALAMETTO RAILROAD MEDICA
TX082186001Medicaid
NM400522213Medicare PIN
TX00DG98Medicare ID - Type Unspecified