POS ESRD Reference Report
Line
Line Descriptions
Value
Type
POS Field
102303
ST MARYS HOSPITAL RENAL DIALYS
WEST PALM BEACH, FL 33407
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
03/02/2005
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
52280
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
09/01/1976
PROV1565
00160
Date of Prior Change in Ownership
DATE
07/01/2001
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102303
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5618446300
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33407
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.65
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
2.00
PROV1075
00640
Registered Nurses
FTES
8.50
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
1.00
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
22
PROV1230
03760
Stations - Total
22
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102510
DIALYSIS ASSOC OF THE PALM BEA
WEST PALM BEACH, FL 33401
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
10/14/2004
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00040
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
09/01/1976
PROV1565
00160
Date of Prior Change in Ownership
DATE
05/31/1995
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102510
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5618330759
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33401
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
1.00
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
4.00
PROV1075
00640
Registered Nurses
FTES
3.00
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
1.00
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
20
PROV1230
03760
Stations - Total
20
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102520
BOCA RATON ARTIFICIAL KIDNEY C
BOCA RATON, FL 33486
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
04/23/2004
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00040
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
09/01/1976
PROV1565
00160
Date of Prior Change in Ownership
DATE
01/31/1995
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102520
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5613923940
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33486
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.20
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
1.00
PROV1075
00640
Registered Nurses
FTES
0.60
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
0.20
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
13
PROV1230
03760
Stations - Total
13
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102527
JUPITER KIDNEY CENTER
JUPITER, FL 33458
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
03
PROV0095
00030
Change of Ownership Date
DATE
11/01/2005
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
01/12/2006
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00090
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
08/01/1978
PROV1565
00160
Date of Prior Change in Ownership
DATE
01/01/1993
PROV1615
00170
Prior Intermediary Number
CODE
PROV1620
00180
Provider Number
CODE
102527
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5617744466
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33458
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.40
PROV0820
00560
Fiscal Year Ending Month/Day
0630
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
0.00
PROV1075
00640
Registered Nurses
FTES
0.19
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
0.40
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
16
PROV1230
03760
Stations - Total
16
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102567
DELRAY ARTIFICIAL KIDNEY CENTE
DELRAY BEACH, FL 33484
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
01/13/2006
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00040
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
09/19/1983
PROV1565
00160
Date of Prior Change in Ownership
DATE
01/31/1995
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102567
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5614950850
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33484
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.50
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
0.00
PROV1075
00640
Registered Nurses
FTES
1.00
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
0.50
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
17
PROV1230
03760
Stations - Total
17
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102571
RENAL CARE CENTER OF BELLE GLA
BELLE GLADE, FL 33430
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
03
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
02/15/2006
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00400
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
08/22/1984
PROV1565
00160
Date of Prior Change in Ownership
DATE
09/30/1995
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102571
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5619960602
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33430
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.50
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
0.00
PROV1075
00640
Registered Nurses
FTES
4.00
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
0.60
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
27
PROV1230
03760
Stations - Total
27
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102582
WEST BOCA DIALYSIS CENTER
BOCA RATON, FL 33434
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
04/13/2005
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00400
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
05/06/1987
PROV1565
00160
Date of Prior Change in Ownership
DATE
06/01/1994
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102582
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5614880202
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33434
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.14
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
1.00
PROV1075
00640
Registered Nurses
FTES
1.82
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
0.25
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
12
PROV1230
03760
Stations - Total
12
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102594
RENAL CARE CENTER OF WELLINGTO
LAKE WORTH, FL 33467
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
02/17/2005
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00400
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
03/14/1988
PROV1565
00160
Date of Prior Change in Ownership
DATE
09/30/1995
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102594
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
4079697799
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33467
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.40
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
0.00
PROV1075
00640
Registered Nurses
FTES
3.00
PROV1145
00790
Facility owned by Organization with over 2 facilit
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
0.60
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
15
PROV1230
03760
Stations - Total
15
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102617
BOYNTON/NORTH DELRAY DIALYSIS
DELRAY BEACH, FL 33445
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
06/23/2004
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00101
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
03/21/1989
PROV1565
00160
Date of Prior Change in Ownership
DATE
05/01/1997
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102617
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
4072764110
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33445
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.75
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
7.00
PROV1075
00640
Registered Nurses
FTES
4.00
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
0.50
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
22
PROV1230
03760
Stations - Total
22
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102634
NORTH PALM BEACH DIALYSIS CTR
PALM BEACH GARDENS, FL 33410
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
04
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
02/22/2007
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00040
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
01/08/1991
PROV1565
00160
Date of Prior Change in Ownership
DATE
11/01/1998
PROV1615
00170
Prior Intermediary Number
CODE
00090
PROV1620
00180
Provider Number
CODE
102634
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5617758700
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33410
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.75
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
1.00
PROV1075
00640
Registered Nurses
FTES
5.00
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
1.00
PROV1185
03510
ESRD Network Number assigned to Facility
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
19
PROV1230
03760
Stations - Total
19
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
102637
LAKE WORTH DIALYSIS
WEST PALM BEACH, FL 33406
A
Subtype of provider
Short Term
PROV0085
00010
Category of Provider/Supplier
ESRD Facility
PROV0075
00020
Change of Ownership Counter
02
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
01/10/2006
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
00101
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
07/15/1991
PROV1565
00160
Date of Prior Change in Ownership
DATE
05/01/1997
PROV1615
00170
Prior Intermediary Number
CODE
00400
PROV1620
00180
Provider Number
CODE
102637
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5614391532
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
For Profit
PROV2885
00310
Provider Zip Code
33406
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Dieticians
FTES
0.25
PROV0820
00560
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
0.00
PROV0955
00580
Other Personnel
FTES
1.00
PROV1075
00640
Registered Nurses
FTES
1.50
PROV1145
00790
Facility owned by Organization with over 2 facilit
Y
PROV0675
02040
Related Provider Number
CODE
PROV1755
02560
Social Workers - Full Time
FTES
0.25
PROV1185
03510
ESRD Network Number assigned to Facility
07
PROV0685
03740
Number of Patients Tuesday 4th shift
0
PROV5540
03750
Stations - Hemodialysis
25
PROV1230
03760
Stations - Total
25
PROV2855
03770
Provider uses Hospital Based Indicators
PROV0565
04190
6/10/2008
11:45:14AM
C
:
\
DOCUME
~
1
\
ROBERT
~
1
\
LOCALS
~
1
\
Temp
\
temp
_
4436
c
59
f
-
d
9
a
1
-
4
a
62
-
ad
49
-
fc
13
f
98
e
51
fb
{
C
7769
B
05
-
79
FD
-
461
C
-
BBA
4
-
442
D
385
C
7
A
8
E
}
.
rpt
Page 11 of 11
11:45 am
www
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.
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6/10/2008
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228
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