Provider Demographics
NPI:1558669978
Name:SNG - SEMINOLE DIALYSIS CENTER LP
Entity Type:Organization
Organization Name:SNG - SEMINOLE DIALYSIS CENTER LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KINAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-725-7900
Mailing Address - Street 1:1000 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3029
Mailing Address - Country:US
Mailing Address - Phone:817-725-7900
Mailing Address - Fax:682-207-1030
Practice Address - Street 1:12581 NS 3540
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-5879
Practice Address - Country:US
Practice Address - Phone:405-382-9809
Practice Address - Fax:405-382-7911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
OK261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200530820AMedicaid
TX372563Medicare Oscar/Certification
TX372563Medicare Oscar/Certification