Provider Demographics
NPI:1366745879
Name:SNG - LEAGUE CITY DIALYSIS LP
Entity type:Organization
Organization Name:SNG - LEAGUE CITY DIALYSIS LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KINAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-725-7900
Mailing Address - Street 1:1000 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3029
Mailing Address - Country:US
Mailing Address - Phone:817-725-7900
Mailing Address - Fax:682-207-1030
Practice Address - Street 1:2785 GULF FWY S STE 145
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4996
Practice Address - Country:US
Practice Address - Phone:832-340-2404
Practice Address - Fax:832-340-2408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
TX261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX364697801Medicaid
TX110079OtherFACILITY LICENSE