Knickerbocker Dialysis Inc

Primary specialty

End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X

Legal business name

KNICKERBOCKER DIALYSIS INC

Doing business as

Grand Boulevard Dialysis

Practice address

860 Grand Blvd
Deer Park, NY 11729-5706

Phone

(631) 243-7770

Fax

(631) 243-7775

NPI assigned

Jun 26, 2019

Organization subpart

No

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

Authorized official

Name

John D Winstel

Title

Chief Accounting Officer

Phone

(253) 733-4501

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Grand Boulevard Dialysis Doing business as

Locations

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

{
    "created_epoch": "1561507200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1626220800000",
    "number": "1386205714",
    "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",
            "telephone_number": "615-341-6410",
            "fax_number": "888-662-8259"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "860 GRAND BLVD",
            "city": "DEER PARK",
            "state": "NY",
            "postal_code": "117295706",
            "telephone_number": "631-243-7770",
            "fax_number": "631-243-7775"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KNICKERBOCKER DIALYSIS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-26",
        "last_updated": "2021-07-14",
        "certification_date": "2021-07-14",
        "status": "A",
        "authorized_official_last_name": "WINSTEL",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "CHIEF ACCOUNTING OFFICER",
        "authorized_official_telephone_number": "253-733-4501"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "06222173",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Grand Boulevard Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Grand Boulevard Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Shelly Kim
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• Katie Kinsedahl
• Kristen Kirkland-Jones
• Michael Kirshblum
• Lastar Knight, LPN
• Danielle Kollmer
• Nicolle C Kollmer
• Justine Marie Koo, PSYD
• Denise Joy Korman

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Deer Park, NY
• Providers in Deer Park, NY by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 14, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.