Organization
QUEENS REPLACEMENT LLC
Active
Other names
Kew Gardens Dialysis Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DOMINIC LICCIARDI (ADMINISTRATOR)
(718) 987-5942
Entity
Organization
Contact information
Practice address
12046 QUEENS BLVD, KEW GARDENS, NY 11415-1204
(718) 793-3341
(718) 268-1666
Mailing address
97 NEW DORP LN, STATEN ISLAND, NY 10306-2364
(718) 448-5641
(718) 876-5969
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
7003264R
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02718005
—
NY
Enumeration date
11/02/2005
Last updated
09/30/2013
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