Basic Information
| Provider Information | |||||||||
| NPI: | 1336174986 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANDCASTLE DIALYSIS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8900 EMMETT F LOWRY EXPY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | TEXAS CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775919119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099330406 | ||||||||
| FaxNumber: | 4099330503 | ||||||||
| Practice Location | |||||||||
| Address1: | 8900 EMMETT F LOWRY EXPY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | TEXAS CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775919119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099330406 | ||||||||
| FaxNumber: | 4099330503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GODINICH | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPHINE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4099330406 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 006484 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.