NPIMap

Organization Active NPI

Knickerbocker Dialysis Inc

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Mount Vernon, NY
National Provider Identifier
1508366386
Registry record updated May 29, 2026
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
Practice address
120 E Sandford Blvd
Mount Vernon, NY 10550-4512
Phone
(914) 665-2035
Fax
(914) 667-5126
NPI assigned
Feb 18, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 29, 2026

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

Authorized official

Name
Samuel Wey
Title
Assistant Secretary
Phone
(615) 341-6641

Specialties & licenses 1

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

Addresses

Primary practice location

120 E Sandford Blvd
Mount Vernon, NY 10550-4512

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
05707391MedicaidNY

Other names 1

  • Sandford Boulevard Dialysis Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180314000454 NY Part A Provider - End-Stage Renal Disease Facility (ESRD) 9436178191 Practice locations: Mount Vernon, NY

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Sandford Boulevard DialysisCCN 332778
Overall star rating
4.0 of 5
Ownership
Profit
Certified
Dec 7, 2018
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
8

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
33D2147969Sandford Boulevard Dialysis120 E Sandford Blvd, Mount Vernon, NY 10550Certificate of waiverMar 26, 2027

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 24

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

View all 24

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": "1518912000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1780012800000",
    "number": "1508366386",
    "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": "120 E SANDFORD BLVD",
            "city": "MOUNT VERNON",
            "state": "NY",
            "postal_code": "105504512",
            "telephone_number": "914-665-2035",
            "fax_number": "914-667-5126"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KNICKERBOCKER DIALYSIS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-18",
        "last_updated": "2026-05-29",
        "certification_date": "2026-05-29",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY",
        "authorized_official_telephone_number": "615-341-6641"
    },
    "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": "05707391",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sandford Boulevard Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mount Vernon, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2026; 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.