Organization
ELLICOTT KIDNEY CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JASON BOUCHER (CFO)
(978) 922-3080
Entity
Organization
Contact information
Practice address
3000 N RIDGE RD, SUITE A, ELLICOTT CITY, MD 21043-3311
(410) 465-0273
(410) 465-0360
Mailing address
3000 N RIDGE RD, SUITE A, ELLICOTT CITY, MD 21043-3311
(410) 465-0273
(410) 465-0360
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
422934700
—
MD
Enumeration date
01/22/2014
Last updated
03/21/2019
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