MEDICARE: KNICKERBOCKER DIALYSIS 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

General Provider Information

NPI Number	:	1154856029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KNICKERBOCKER DIALYSIS INC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L & C DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-320-4414
Fax Number	:	866-865-2884

Provider Business Practice Location Address
First Line	:	113 CROSSWAYS PARK DR
Second Line	:	SUITE 102
City	:	WOODBURY
State	:	NY
Zip	:	11797-2044
Country	:	US
Telephone Number	:	516-921-0914
Fax Number	:	516-364-0164

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	JAMES K HILGER
Credential	:
Telephone Number	:	615-320-4414

Provider Enumeration Date	:	04/27/2017
Last Update Date	:	04/27/2017

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