Provider Demographics
NPI:1548489586
Name:DAUGHTERS OF JACOB DIALYSIS CENTER CORP
Entity type:Organization
Organization Name:DAUGHTERS OF JACOB DIALYSIS CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-644-9276
Mailing Address - Street 1:1160 TELLER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-4145
Mailing Address - Country:US
Mailing Address - Phone:718-293-1500
Mailing Address - Fax:
Practice Address - Street 1:1160 TELLER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-4145
Practice Address - Country:US
Practice Address - Phone:718-293-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02684059Medicaid
332648Medicare ID - Type UnspecifiedPROVIDER NUMBER