Provider Demographics
NPI:1699779611
Name:KIDNEY TREATMENT CENTER EAST P A
Entity type:Organization
Organization Name:KIDNEY TREATMENT CENTER EAST P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MEDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-692-1515
Mailing Address - Street 1:3939 MEDICAL DR
Mailing Address - Street 2:# 110
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2291
Mailing Address - Country:US
Mailing Address - Phone:210-692-1515
Mailing Address - Fax:210-692-0187
Practice Address - Street 1:1608 S NEW BRAUNFELS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78210-2253
Practice Address - Country:US
Practice Address - Phone:210-531-9522
Practice Address - Fax:210-531-9817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007035261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0943250-01Medicaid
TX0943250-02Medicaid
TXHH6395OtherBCBS
TX452804Medicare ID - Type Unspecified
TX0943250-02Medicaid