Basic Information
Provider Information
NPI: 1619230075
EntityType: 2
ReplacementNPI:  
OrganizationName: SNG - SAN AUGUSTINE DIALYSIS CENTER LP
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Mailing Information
Address1: 1000 W CANNON ST
Address2:  
City: FORT WORTH
State: TX
PostalCode: 761043029
CountryCode: US
TelephoneNumber: 8177257900
FaxNumber: 6822071030
Practice Location
Address1: 403 N MILAM ST
Address2:  
City: SAN AUGUSTINE
State: TX
PostalCode: 759722228
CountryCode: US
TelephoneNumber: 9362753600
FaxNumber: 9362753602
Other Information
ProviderEnumerationDate: 06/20/2012
LastUpdateDate: 07/21/2022
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: MARTIN
AuthorizedOfficialFirstName: KINAM
AuthorizedOfficialMiddleName: C.
AuthorizedOfficialTitleorPosition: CHIEF OPERATIONS OFFICER
AuthorizedOfficialTelephone: 8177257900
IsSoleProprietor:  
IsOrganizationSubpart: N
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QE0700X  Y Ambulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment

ID Information
IDTypeStateIssuerDescription
11011401TXFACILITY LICENSEOTHER
31985900105TX MEDICAID


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