Basic Information
| Provider Information | |||||||||
| NPI: | 1548489586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAUGHTERS OF JACOB DIALYSIS CENTER CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 TELLER AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104564145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182931500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1160 TELLER AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104564145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182931500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KORBA | ||||||||
| AuthorizedOfficialFirstName: | COREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9146449276 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 02684059 | 05 | NY | MEDICAID |