Provider Demographics
NPI:1730187493
Name:KIDNEY GROUP OF SOUTH FLORIDA PA
Entity type:Organization
Organization Name:KIDNEY GROUP OF SOUTH FLORIDA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:VALLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-771-3929
Mailing Address - Street 1:2001 NE 48TH CT
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4512
Mailing Address - Country:US
Mailing Address - Phone:954-771-3929
Mailing Address - Fax:954-771-2393
Practice Address - Street 1:2001 NE 48TH CT
Practice Address - Street 2:SUITE 4
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4512
Practice Address - Country:US
Practice Address - Phone:954-771-3929
Practice Address - Fax:954-771-2393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40127Medicare ID - Type Unspecified