Provider Demographics
NPI:1558181636
Name:ROCKY MOUNTAIN KIDNEY CARE PROFESSIONAL SERVICE CORP
Entity type:Organization
Organization Name:ROCKY MOUNTAIN KIDNEY CARE PROFESSIONAL SERVICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DITTRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-590-5955
Mailing Address - Street 1:5851 LEGACY CIR STE 900
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-5982
Mailing Address - Country:US
Mailing Address - Phone:469-590-5955
Mailing Address - Fax:
Practice Address - Street 1:5851 LEGACY CIR STE 900
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-5982
Practice Address - Country:US
Practice Address - Phone:469-590-5955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-14
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty