NPIMap

Organization Active NPI

Knickerbocker Dialysis Inc

Doing business as Laconia Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Bronx, NY
National Provider Identifier
1063932945
Registry record updated Nov 1, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
KNICKERBOCKER DIALYSIS INC
Doing business as
Laconia Dialysis
Practice address
3440 Boston Rd
Bronx, NY 10469-2512
Phone
(718) 798-0538
Fax
(718) 652-2495
NPI assigned
Jun 22, 2017
Last updated
Nov 1, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 1, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Samuel Wey
Title
VP, Licensure & Certification
Phone
(615) 341-6641

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X NU Primary

Addresses

Primary practice location

3440 Boston Rd
Bronx, NY 10469-2512

Mailing address

5200 Virginia Way
L&C Dept
Brentwood, TN 37027-7569

Other identifiers 1

IdentifierTypeStateIssuer
05872784MedicaidNY

Other names 1

  • Laconia Dialysis Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170707002711 NY Part A Provider - End-Stage Renal Disease Facility (ESRD) 9436178191 Practice locations: Bronx, NY

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Laconia DialysisCCN 332786
Overall star rating
3.0 of 5
Ownership
Profit
Certified
Feb 26, 2019
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
24

Name & address match This facility record has no NPI; it was connected to this NPI by matching name and address.

National Provider Directory

National Provider Directory
Tax ID family
Knickerbocker Dialysis Inc65 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 18

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 18

Locations

3440 Boston Rd
Bronx, NY 10469
Phone (718) 798-0538

Practitioners & affiliated clinicians

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1498089600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730419200000",
    "number": "1063932945",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "L&C DEPT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370277569"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3440 BOSTON RD",
            "city": "BRONX",
            "state": "NY",
            "postal_code": "104692512",
            "telephone_number": "718-798-0538",
            "fax_number": "718-652-2495"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KNICKERBOCKER DIALYSIS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-22",
        "last_updated": "2024-11-01",
        "certification_date": "2024-11-01",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "VP, LICENSURE & CERTIFICATION",
        "authorized_official_telephone_number": "615-341-6641"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05872784",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Laconia Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Laconia Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bronx, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.