MEDICARE: VESTAL HEALTHCARE, 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

General Provider Information

NPI Number	:	1952768640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VESTAL HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	1776 EASTCHESTER RD
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10461-2341
Country	:	US
Telephone Number	:	718-239-2089
Fax Number	:	718-239-2385

Provider Business Practice Location Address
First Line	:	1776 EASTCHESTER RD
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10461-2341
Country	:	US
Telephone Number	:	718-239-2089
Fax Number	:	718-239-2385

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARK CAPUTO
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	01/26/2016
Last Update Date	:	03/01/2016

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