MEDICARE: SATELLITE DIALYSIS-CENTRAL MODESTO LLC

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	110000527	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110000527	OTHER	CA	STATE OF CALIFORNIA

General Provider Information

NPI Number	:	1609847581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SATELLITE DIALYSIS-CENTRAL MODESTO LLC

Provider Business Mailing Address
First Line	:	5851 LEGACY CIR STE 900
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-5982
Country	:	US
Telephone Number	:	214-736-2700
Fax Number	:	214-975-2435

Provider Business Practice Location Address
First Line	:	1315 10TH ST
Second Line	:	SUITE 300
City	:	MODESTO
State	:	CA
Zip	:	95354-0714
Country	:	US
Telephone Number	:	209-238-4087
Fax Number	:	209-238-4092

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL, PRESIDENT & CH
Name	:	THOMAS L. WEINBERG
Credential	:
Telephone Number	:	214-736-2730

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	05/15/2024

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