Provider Demographics
NPI:1730219924
Name:KENOSHA KIDNEY DIALYSIS LLC
Entity type:Organization
Organization Name:KENOSHA KIDNEY DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3080
Mailing Address - Street 1:6125 GREEN BAY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2942
Mailing Address - Country:US
Mailing Address - Phone:262-652-1776
Mailing Address - Fax:262-652-2702
Practice Address - Street 1:6125 GREEN BAY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2942
Practice Address - Country:US
Practice Address - Phone:262-652-1776
Practice Address - Fax:262-652-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2017-03-16
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
WI42064600Medicaid
WI42064600Medicaid