=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528424975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NCPDC KIDNEY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2016
-----------------------------------------------------
Last Update Date | 01/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 PLAZA LN
-----------------------------------------------------
City | WELLSBORO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16901-1766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-781-6212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4822 MARKET ST SUITE 300
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-781-6212
-----------------------------------------------------
Fax | 330-953-2041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | CHESTER A AMEDIA JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-781-6212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------