MEDICARE: KIDNEY CENTER OF VINELAND 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

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

General Provider Information

NPI Number	:	1619907417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY CENTER OF VINELAND LLC

Provider Business Mailing Address
First Line	:	333 IRVING AVE
Second Line	:
City	:	BRIDGETON
State	:	NJ
Zip	:	08302-2123
Country	:	US
Telephone Number	:	856-575-4742
Fax Number	:	856-451-5269

Provider Business Practice Location Address
First Line	:	1318 S MAIN RD
Second Line	:
City	:	VINELAND
State	:	NJ
Zip	:	08360-6516
Country	:	US
Telephone Number	:	856-575-4742
Fax Number	:	856-451-5269

Authorized Official
Title or Position	:	GOVERNMENT BILLING SUPERVISOR
Name	:	MRS. BEVERLY EDISS
Credential	:
Telephone Number	:	856-575-4742

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	05/30/2008

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