Provider Demographics
NPI:1063034866
Name:SATELLITE DIALYSIS OF CENTRAL MERCED LLC
Entity Type:Organization
Organization Name:SATELLITE DIALYSIS OF CENTRAL MERCED LLC
Other - Org Name:SATELLITE HEALTHCARE CENTRAL MERCED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-404-3600
Mailing Address - Street 1:300 SANTANA ROW STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2424
Mailing Address - Country:US
Mailing Address - Phone:650-404-3600
Mailing Address - Fax:650-625-6007
Practice Address - Street 1:66 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3134
Practice Address - Country:US
Practice Address - Phone:209-600-4701
Practice Address - Fax:650-625-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
366554OtherBUSINESS LICENSE