Provider Demographics
NPI:1245831767
Name:CVS-SHC KIDNEY CARE HOME DIALYSIS OF PHILADELPHIA LLC
Entity type:Organization
Organization Name:CVS-SHC KIDNEY CARE HOME DIALYSIS OF PHILADELPHIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-290-5964
Mailing Address - Street 1:300 SANTANA ROW STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2424
Mailing Address - Country:US
Mailing Address - Phone:669-236-5947
Mailing Address - Fax:650-625-6007
Practice Address - Street 1:1945 ROUTE 70 E STE A
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2117
Practice Address - Country:US
Practice Address - Phone:856-229-8010
Practice Address - Fax:856-751-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
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
NJ25196OtherSTATE LICENSE