NPIMap

Organization Active NPI

Dialysis Clinic Inc.

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Jacksonville, FL
National Provider Identifier
1720011109
Registry record updated Oct 5, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
DIALYSIS CLINIC INC.
Practice address
11705 San Jose Blvd Ste 100
Jacksonville, FL 32223-1628
Phone
(904) 296-6362
Fax
(904) 296-6473
NPI assigned
Jul 8, 2006
Last updated
Oct 5, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 5, 2023

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

Authorized official

Name
Mr. Donovan Schultz
Title
President
Phone
(615) 327-3061

Specialties & licenses 1

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

Addresses

Primary practice location

11705 San Jose Blvd Ste 100
Jacksonville, FL 32223-1628

Mailing address

757 Union St W
Jacksonville, FL 32202-4765
Phone (904) 354-0409

Other identifiers 1

IdentifierTypeStateIssuer
2103478-00MedicaidFL

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080717000307 FL Part A Provider - End-Stage Renal Disease Facility (ESRD) 4284541129 Practice locations: Jacksonville, FL

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
Dialysis Clinic Inc of SouthpointCCN 102649
Overall star rating
2.0 of 5
Ownership
Non-profit
Certified
Jul 6, 1992
Medicare certification status
ActiveFrom the Provider of Services file
Chain
Dialysis Clinic, Inc.
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
Dialysis Clinic Inc238 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 6

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

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Rancho Dialysis ClinicSacramento, CA, CCN 552519 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Dec 24, 2003
Dec 24, 2003

Practitioners & affiliated clinicians

Affiliated clinicians 3

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": "1152316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696464000000",
    "number": "1720011109",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "757 UNION ST W",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322024765",
            "telephone_number": "904-354-0409",
            "fax_number": "904-354-0416"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11705 SAN JOSE BLVD STE 100",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322231628",
            "telephone_number": "904-296-6362",
            "fax_number": "904-296-6473"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DIALYSIS CLINIC INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-08",
        "last_updated": "2023-10-05",
        "certification_date": "2023-10-05",
        "status": "A",
        "authorized_official_last_name": "SCHULTZ",
        "authorized_official_first_name": "DONOVAN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "615-327-3061",
        "authorized_official_name_prefix": "Mr."
    },
    "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": "2103478-00",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, FL

Sources for this page

Verify at the official NPI Registry.