NPIMap

Organization Active NPI

South Fork Dialysis LLC

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Fresno, CA
National Provider Identifier
1659647808
Registry record updated Feb 17, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
License
550002083 Issued in CA
Legal business name
SOUTH FORK DIALYSIS LLC
Practice address
560 E Herndon Ave
Ste 101
Fresno, CA 93720-2907
Phone
(559) 432-5278
Fax
(559) 435-1422
NPI assigned
Mar 31, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 17, 2022

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

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X 550002083 CA Primary

Addresses

Primary practice location

560 E Herndon Ave
Ste 101
Fresno, CA 93720-2907

Mailing address

5200 Virginia Way
L&C Dept
Brentwood, TN 37027-7569
Phone (615) 238-3085

Other identifiers 1

IdentifierTypeStateIssuer
1659647808MedicaidCA

Other names 1

  • Herndon Dialysis Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120519000036 CA Part A Provider - End-Stage Renal Disease Facility (ESRD) 3971766437 Practice locations: Fresno, CA

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Herndon DialysisCCN 552702
Overall star rating
3.0 of 5
Ownership
Profit
Certified
Sep 26, 2012
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
48

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
05D2043939Herndon Dialysis560 E Herndon Ave Ste 101, Fresno, CA 93720Certificate of waiverJul 12, 2028

National Provider Directory

National Provider Directory

Member of 2

Organizations this organization is a member of, according to the National Provider Directory.

Practitioners & affiliated clinicians

Affiliated clinicians 9

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": "1333152000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1645056000000",
    "number": "1659647808",
    "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": "615-238-3085",
            "fax_number": "800-268-9682"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "560 E HERNDON AVE",
            "address_2": "STE 101",
            "city": "FRESNO",
            "state": "CA",
            "postal_code": "937202907",
            "telephone_number": "559-432-5278",
            "fax_number": "559-435-1422"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH FORK DIALYSIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-03-31",
        "last_updated": "2022-02-17",
        "certification_date": "2022-02-17",
        "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": "CA",
            "license": "550002083",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1659647808",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Herndon Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Herndon Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fresno, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2022; 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.