Healthcare Provider Details

I. General information

NPI: 1093769739
Provider Name (Legal Business Name): ST. JUDE RENAL CARE FACILITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KULOT DI ROSA DR., CHALAN KIYA SAIPAN HEALTH CLINIC BUILDING
SAIPAN MP
96950-2878
US

IV. Provider business mailing address

PO BOX 502878
SAIPAN MP
96950-2878
US

V. Phone/Fax

Practice location:
  • Phone: 670-234-2901
  • Fax: 670-234-2906
Mailing address:
  • Phone: 670-234-2901
  • Fax: 670-234-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number StateMP

VIII. Authorized Official

Name: JESSE SABLAN
Title or Position: ADMIN. / IT ASSISTANT
Credential:
Phone: 670-234-2901