Provider Demographics
NPI:1104190826
Name:SATELLITE DIALYSIS OF SOUTH STOCKTON LLC
Entity Type:Organization
Organization Name:SATELLITE DIALYSIS OF SOUTH STOCKTON LLC
Other - Org Name:SATELLITE HEALTHCARE UNIVERSITY PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/COO
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
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2423
Mailing Address - Country:US
Mailing Address - Phone:209-774-5800
Mailing Address - Fax:650-625-6007
Practice Address - Street 1:590 E HARDING WY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6110
Practice Address - Country:US
Practice Address - Phone:209-774-5800
Practice Address - Fax:209-462-2118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SATELLITE HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-27
Last Update Date:2023-01-17
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
CA1104190826Medicaid
CA550002047OtherSTATE OF CALIFORNIA
CA550002047OtherSTATE OF CALIFORNIA