Basic Information
| Provider Information | |||||||||
| NPI: | 1891013322 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SNG - BARLITE SAN SABA DIALYSIS CENTERS 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: | 315 N SAN SABA STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107981955 | ||||||||
| FaxNumber: | 2107981451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2010 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | KINAM | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8177257900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 284642001 | 05 | TX | MEDICAID | 110054 | 01 | TX | FACILITY LICENSE | OTHER |