Provider Demographics
NPI:1356783724
Name:DEARBORN KIDNEY CENTER LLC
Entity type:Organization
Organization Name:DEARBORN 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 1:5111 AUTO CLUB DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2684
Mailing Address - Country:US
Mailing Address - Phone:313-982-9788
Mailing Address - Fax:313-982-9789
Practice Address - Street 1:5111 AUTO CLUB DR
Practice Address - Street 2:SUITE 120
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2684
Practice Address - Country:US
Practice Address - Phone:313-982-9788
Practice Address - Fax:313-982-9789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2023-01-10
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
MI1356783724Medicaid
MI232694Medicare Oscar/Certification