1770903171 NPI number — SNG - BELLAIRE DIALYSIS CENTER LP

Table of content: (NPI 1770903171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770903171 NPI number — SNG - BELLAIRE DIALYSIS CENTER LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SNG - BELLAIRE DIALYSIS CENTER LP
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:
1770903171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 W CANNON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-3029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-725-7900
Provider Business Mailing Address Fax Number:
682-207-1030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7243 BISSONNET ST
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77074-5801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-988-7200
Provider Business Practice Location Address Fax Number:
713-988-7201
Provider Enumeration Date:
04/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
KINAM
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
CHIEF OPERATIONS OFFICER
Authorized Official Telephone Number:
817-725-7900

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: 110246 . This is a "FACILITY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 366459101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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