Provider Demographics
NPI:1093769739
Name:ST. JUDE RENAL CARE FACILITY, INC.
Entity Type:Organization
Organization Name:ST. JUDE RENAL CARE FACILITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN. / IT ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:SABLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:670-234-2901
Mailing Address - Street 1:PO BOX 502878
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950-2878
Mailing Address - Country:US
Mailing Address - Phone:670-234-2901
Mailing Address - Fax:670-234-2906
Practice Address - Street 1:KULOT DI ROSA DR., CHALAN KIYA
Practice Address - Street 2:SAIPAN HEALTH CLINIC BUILDING
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950-2878
Practice Address - Country:US
Practice Address - Phone:670-234-2901
Practice Address - Fax:670-234-2906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
MP261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP662501Medicare Oscar/Certification