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General NPI Number Information
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NPI Number | 1366876948
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Entity Type | Organization
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Legal Business Name | KNICKERBOCKER DIALYSIS INC
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Dates
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Enumeration Date | 08/30/2013
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Last Update Date | 02/29/2024
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Provider Practice Location Address
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Address Line | 1139 HYLAN BLVD
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City | STATEN ISLAND
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State | NY
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Zip | 10305-2061
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Country | US
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Telephone | 718-816-4913
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Fax | 718-816-6340
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Provider Business Mailing Address
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Address Line | 5200 VIRGINIA WAY L & C DEPT
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City | BRENTWOOD
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State | TN
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Zip | 37027-7569
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Country | US
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Telephone | 615-341-6410
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Fax | 888-662-8259
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Authorized Official
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Title or Position | VP, LICENSURE & CERTIFICATION
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Name | SAMUEL WEY
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Credential |
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Telephone | 615-341-6641
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | 7000272R
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License Number State | NY
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