Provider Demographics
NPI:1972056893
Name:PROVO KIDNEY CARE LLC
Entity type:Organization
Organization Name:PROVO KIDNEY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:VP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-639-7186
Mailing Address - Street 1:920 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1521
Mailing Address - Country:US
Mailing Address - Phone:480-639-7186
Mailing Address - Fax:602-798-8267
Practice Address - Street 1:920 WINTER ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1521
Practice Address - Country:US
Practice Address - Phone:480-639-7186
Practice Address - Fax:602-798-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT001207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty