Knickerbocker Dialysis Inc

Primary specialty

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

Legal business name

KNICKERBOCKER DIALYSIS INC

Doing business as

Half Moon Dialysis

Practice address

1633 Route 202 Ste 120
Pomona, NY 10970-2926

Phone

(845) 364-9101

Fax

(845) 364-9106

NPI assigned

Dec 24, 2019

Organization subpart

No

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) 341-6410

Specialties & licenses 1

Addresses

Other names 1

• Half Moon Dialysis Doing business as

Locations

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

{
    "created_epoch": "1577145600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699574400000",
    "number": "1629617576",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "L AND C DEPT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370277569",
            "telephone_number": "615-320-4414",
            "fax_number": "866-865-2884"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1633 ROUTE 202 STE 120",
            "city": "POMONA",
            "state": "NY",
            "postal_code": "109702926",
            "telephone_number": "845-364-9101",
            "fax_number": "845-364-9106"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KNICKERBOCKER DIALYSIS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-24",
        "last_updated": "2023-11-10",
        "certification_date": "2023-11-10",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "VP LICENSURE & CERTIFICATION",
        "authorized_official_telephone_number": "615-341-6410"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Half Moon Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Half Moon Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Alireza Mahyar Khavari, DDS
• Mary Kilbride, MA
• Lisa Kirk, LCSW
• Shira Kirshblum
• Sherie Antwanette Kitchings, MS SPED
• Kayla Koenig
• Itta T Kogan, OT
• Stephen M Koretsky, PH.D.
• Carol Korngold, LCSW
• Bernard Steven Korotkin, RN

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Pomona, NY
• Providers in Pomona, 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 Nov 10, 2023; 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.