Provider Demographics
NPI:1275595571
Name:HORTENSE & LOUIS RUBIN DIALYSIS CENTER, INC.
Entity Type:Organization
Organization Name:HORTENSE & LOUIS RUBIN DIALYSIS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:EVANCOE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:518-271-0702
Mailing Address - Street 1:59C MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1012
Mailing Address - Country:US
Mailing Address - Phone:518-587-1919
Mailing Address - Fax:518-587-1313
Practice Address - Street 1:59C MYRTLE ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1012
Practice Address - Country:US
Practice Address - Phone:518-587-1919
Practice Address - Fax:518-587-1313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4102201R261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10005842OtherCDPHP
NY00964250Medicaid
NY955428OtherMVP
NY000400438002OtherBSNENY
NY332557Medicare ID - Type UnspecifiedSARATOGA