Provider Demographics
NPI:1427281971
Name:KIDNEY CLINIC OF JACKSONVILLE, LLC
Entity type:Organization
Organization Name:KIDNEY CLINIC OF JACKSONVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KADIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-296-8980
Mailing Address - Street 1:14546 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:301
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5468
Mailing Address - Country:US
Mailing Address - Phone:904-296-8980
Mailing Address - Fax:904-296-0698
Practice Address - Street 1:14546 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:301
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5468
Practice Address - Country:US
Practice Address - Phone:904-296-8980
Practice Address - Fax:904-296-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty