KNICKERBOCKER DIALYSIS INC NPI 1386205714

NPI Information

NPI: 1386205714
Provider Name: KNICKERBOCKER DIALYSIS INC

Doing Business As: GRAND BOULEVARD DIALYSIS

Classification: Clinic/Center - 261QE0700X
Entity Type: Organization

Specialization: End-Stage Renal Disease (ESRD) Treatment

Address:
860 GRAND BLVD
DEER PARK, NY
ZIP 11729
Phone: (631) 243-7770
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KNICKERBOCKER DIALYSIS INC is an end-stage renal disease (esrd) treatment clinic center in Deer Park, NY. KNICKERBOCKER DIALYSIS INC NPI is 1386205714. The provider is registered as an organization entity type.
The provider Is Doing Business As Grand Boulevard Dialysis.

The provider's business location address is:

860 GRAND BLVD
DEER PARK, NY
ZIP 11729-706
Phone: (631) 243-7770
Fax: (631) 243-7775

The provider's authorized official is John D Winstel .
The authorized official title is Chief Accounting Officer and has the following contact phone number (253) 733-4501.

The CLIA number assigned to this NPI record is 33D2171632 - end stage renal disease dialysis facility with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 6/26/2019 and was last updated on 7/14/2021.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	261QE0700X	Clinic/Center	End-Stage Renal Disease (ESRD) Treatment			Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	06222173	MEDICAID	NEW YORK

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 5/5/2024

NPI Synchronization or Removal

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