MEDICARE: KIDNEY TREATMENT CENTER SAN ANTONIO 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	000043	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	HH6150	OTHER	TX	BC/BS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225032253
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY TREATMENT CENTER SAN ANTONIO INC

Provider Business Mailing Address
First Line	:	3939 MEDICAL DR STE 110
Second Line	:	STE 110
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-2292
Country	:	US
Telephone Number	:	210-692-1515
Fax Number	:	210-692-0187

Provider Business Practice Location Address
First Line	:	803 CASTROVILLE RD
Second Line	:	STE 401
City	:	SAN ANTONIO
State	:	TX
Zip	:	78237-3148
Country	:	US
Telephone Number	:	210-435-4725
Fax Number	:	210-433-8826

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	MRS. JESSICA J MEDOLA
Credential	:
Telephone Number	:	210-692-1515

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	04/07/2010

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