MEDICARE: UNIVERSAL KIDNEY CENTER OF BOYNTON BEACH 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	CLEA LIC # 800017018	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VE9	OTHER	FL	BCBS OF FL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245342658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSAL KIDNEY CENTER OF BOYNTON BEACH INC

Provider Business Mailing Address
First Line	:	4895 WINDWARD PASSAGE DRIVE
Second Line	:	SUITE #5
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-7741
Country	:	US
Telephone Number	:	561-740-1981
Fax Number	:	561-732-8288

Provider Business Practice Location Address
First Line	:	4895 WINDWARD PASSAGE DRIVE
Second Line	:	SUITE #5
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-7741
Country	:	US
Telephone Number	:	561-740-1981
Fax Number	:	561-732-8288

Authorized Official
Title or Position	:	CFO COO
Name	:	MR. ELMO ANGELO V BARTOLOME
Credential	:
Telephone Number	:	954-770-6540

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	10/06/2015

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