Basic Information
| Provider Information | |||||||||
| NPI: | 1427281971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDNEY CLINIC OF JACKSONVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14546 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | 301 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322585468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042968980 | ||||||||
| FaxNumber: | 9042960698 | ||||||||
| Practice Location | |||||||||
| Address1: | 14546 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | 301 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322585468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042968980 | ||||||||
| FaxNumber: | 9042960698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2009 | ||||||||
| LastUpdateDate: | 12/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | MANSUR | ||||||||
| AuthorizedOfficialFirstName: | KADIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9042968980 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.