Provider Demographics
NPI:1336174986
Name:SANDCASTLE DIALYSIS LLC
Entity type:Organization
Organization Name:SANDCASTLE DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JOSEPHINE
Authorized Official - Last Name:GODINICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:409-933-0406
Mailing Address - Street 1:8900 EMMETT F LOWRY EXPY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77591-9119
Mailing Address - Country:US
Mailing Address - Phone:409-933-0406
Mailing Address - Fax:409-933-0503
Practice Address - Street 1:8900 EMMETT F LOWRY EXPY
Practice Address - Street 2:SUITE 201
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-9119
Practice Address - Country:US
Practice Address - Phone:409-933-0406
Practice Address - Fax:409-933-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX006484261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX452757Medicare ID - Type Unspecified