Provider Demographics
NPI:1699417824
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:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:669-266-6359
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 1:1939 MACDADE BOULEVARD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:PA
Practice Address - Zip Code:19033-1214
Practice Address - Country:US
Practice Address - Phone:610-616-5555
Practice Address - Fax:610-461-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
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
PA03312022OtherASSUMED NAME