Provider Demographics
NPI:1871526202
Name:ATLANTIC KIDNEY CENTER LLC
Entity type:Organization
Organization Name:ATLANTIC KIDNEY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:4700 N CONGRESS AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3284
Mailing Address - Country:US
Mailing Address - Phone:561-845-2888
Mailing Address - Fax:561-845-7282
Practice Address - Street 1:4700 N CONGRESS AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3284
Practice Address - Country:US
Practice Address - Phone:561-845-2888
Practice Address - Fax:561-845-7282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891221100Medicaid
FL891221100Medicaid