Provider Demographics
NPI:1063860724
Name:BELLEVILLE KIDNEY CLINIC, LLC
Entity type:Organization
Organization Name:BELLEVILLE KIDNEY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSHCA
Authorized Official - Phone:973-450-1560
Mailing Address - Street 1:500 CORTLANDT ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-3331
Mailing Address - Country:US
Mailing Address - Phone:718-268-7347
Mailing Address - Fax:718-575-3375
Practice Address - Street 1:500 CORTLANDT ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3331
Practice Address - Country:US
Practice Address - Phone:718-268-7347
Practice Address - Fax:718-575-3375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
NJ261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment