1699417824 NPI number — CVS-SHC KIDNEY CARE HOME DIALYSIS OF PHILADELPHIA LLC

Table of content: (NPI 1699417824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699417824 NPI number — CVS-SHC KIDNEY CARE HOME DIALYSIS OF PHILADELPHIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CVS-SHC KIDNEY CARE HOME DIALYSIS OF PHILADELPHIA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699417824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 SANTANA ROW STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95128-2424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
669-236-5947
Provider Business Mailing Address Fax Number:
650-625-6007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1939 MACDADE BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19033-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-616-5555
Provider Business Practice Location Address Fax Number:
610-461-3424
Provider Enumeration Date:
04/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
VINCENT
Authorized Official First Name:
BERNADETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/COO
Authorized Official Telephone Number:
669-266-6359

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03312022 . This is a "ASSUMED NAME" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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