Healthcare Provider Details

I. General information

NPI: 1619907417
Provider Name (Legal Business Name): KIDNEY CENTER OF VINELAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 S MAIN RD
VINELAND NJ
08360-6516
US

IV. Provider business mailing address

333 IRVING AVE
BRIDGETON NJ
08302-2123
US

V. Phone/Fax

Practice location:
  • Phone: 856-575-4742
  • Fax: 856-451-5269
Mailing address:
  • Phone: 856-575-4742
  • Fax: 856-451-5269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. BEVERLY EDISS
Title or Position: GOVERNMENT BILLING SUPERVISOR
Credential:
Phone: 856-575-4742