Organization
KIDNEY TREATMENT CENTER EAST P A
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JESSICA J MEDOLA (SUPERVISOR)
(210) 692-1515
Entity
Organization
Contact information
Practice address
1608 S NEW BRAUNFELS AVE, SAN ANTONIO, TX 78210-2253
(210) 531-9522
(210) 531-9817
Mailing address
3939 MEDICAL DR, # 110, SAN ANTONIO, TX 78229-2291
(210) 692-1515
(210) 692-0187
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
007035
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0943250-01
—
TX
05
—
0943250-02
—
TX
01
—
HH6395
BCBS
TX
Enumeration date
06/08/2005
Last updated
02/24/2012
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