Organization
KENOSHA KIDNEY DIALYSIS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JONATHAN WILCOX (CFO)
(978) 922-3080
Entity
Organization
Contact information
Practice address
6125 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2942
(262) 652-1776
(262) 652-2702
Mailing address
6125 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2942
(262) 652-1776
(262) 652-2702
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
—
42064600
—
WI
Enumeration date
03/06/2007
Last updated
03/16/2017
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