MEDICARE: SATELLITE DIALYSIS OF ORANGE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	550000808	OTHER	CA	CDPH
2	05D1085700	OTHER		CLIA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386822088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SATELLITE DIALYSIS OF ORANGE LLC

Provider Business Mailing Address
First Line	:	300 SANTANA ROW
Second Line	:	SUITE 300
City	:	SAN JOSE
State	:	CA
Zip	:	95128-2423
Country	:	US
Telephone Number	:	714-285-9675
Fax Number	:	650-625-6008

Provider Business Practice Location Address
First Line	:	1518 W LA VETA AVE
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4117
Country	:	US
Telephone Number	:	714-285-9675
Fax Number	:	714-285-9681

Authorized Official
Title or Position	:	PRESIDENT/COO
Name	:	BERNADETTE VINCENT
Credential	:
Telephone Number	:	650-404-3600

Provider Enumeration Date	:	02/05/2008
Last Update Date	:	01/17/2023

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