Provider Demographics
NPI:1245342658
Name:UNIVERSAL KIDNEY CENTER OF BOYNTON BEACH INC
Entity type:Organization
Organization Name:UNIVERSAL KIDNEY CENTER OF BOYNTON BEACH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ELMO
Authorized Official - Middle Name:ANGELO V
Authorized Official - Last Name:BARTOLOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-770-6540
Mailing Address - Street 1:4895 WINDWARD PASSAGE DRIVE
Mailing Address - Street 2:SUITE #5
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-7741
Mailing Address - Country:US
Mailing Address - Phone:561-740-1981
Mailing Address - Fax:561-732-8288
Practice Address - Street 1:4895 WINDWARD PASSAGE DRIVE
Practice Address - Street 2:SUITE #5
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-7741
Practice Address - Country:US
Practice Address - Phone:561-740-1981
Practice Address - Fax:561-732-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCLEA LIC # 800017018261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVE9OtherBCBS OF FL
FL890071000Medicaid
FL102782Medicare Oscar/Certification