Provider Demographics
NPI:1114546256
Name:KNICKERBOCKER DIALYSIS INC
Entity Type:Organization
Organization Name:KNICKERBOCKER DIALYSIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WINSTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-320-4414
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L AND C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4414
Mailing Address - Fax:866-865-2884
Practice Address - Street 1:21910 S CONDUIT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-3462
Practice Address - Country:US
Practice Address - Phone:718-341-0107
Practice Address - Fax:718-341-2255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVITA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment