Healthcare Provider Details

I. General information

NPI: 1295931624
Provider Name (Legal Business Name): KEW GARDENS DIALYSIS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12046 QUEENS BLVD
KEW GARDENS NY
11415-1204
US

IV. Provider business mailing address

97 NEW DORP LN
STATEN ISLAND NY
10306-2364
US

V. Phone/Fax

Practice location:
  • Phone: 718-793-3341
  • Fax: 718-268-1666
Mailing address:
  • Phone: 718-448-5641
  • Fax: 718-876-5969

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: MR. DOMINIC LICCIARDI
Title or Position: COO
Credential:
Phone: 718-987-5942