MEDICARE: ST. JUDE RENAL CARE FACILITY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center
2	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center		MP

General Provider Information

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

Provider Business Mailing Address
First Line	:	PO BOX 502878
Second Line	:
City	:	SAIPAN
State	:	MP
Zip	:	96950-2878
Country	:	US
Telephone Number	:	670-234-2901
Fax Number	:	670-234-2906

Provider Business Practice Location Address
First Line	:	KULOT DI ROSA DR., CHALAN KIYA
Second Line	:	SAIPAN HEALTH CLINIC BUILDING
City	:	SAIPAN
State	:	MP
Zip	:	96950-2878
Country	:	US
Telephone Number	:	670-234-2901
Fax Number	:	670-234-2906

Authorized Official
Title or Position	:	ADMIN. / IT ASSISTANT
Name	:	JESSE SABLAN
Credential	:
Telephone Number	:	670-234-2901

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	04/14/2014

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Directions to “ST. JUDE RENAL CARE FACILITY, INC. ” Practice Location

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