Provider Demographics
NPI:1689103335
Name:LAFAYETTE KIDNEY CARE LLC
Entity type:Organization
Organization Name:LAFAYETTE KIDNEY CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9362
Mailing Address - Street 1:301 4TH ST STE 30105
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8420
Mailing Address - Country:US
Mailing Address - Phone:318-483-1961
Mailing Address - Fax:318-483-1964
Practice Address - Street 1:201 4TH ST STE 5A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8421
Practice Address - Country:US
Practice Address - Phone:318-483-1961
Practice Address - Fax:318-483-1964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-07
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2460960Medicaid