1265403976 NPI number — OAKDALE KIDNEY CENTER, LLC

Table of content: (NPI 1265403976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265403976 NPI number — OAKDALE KIDNEY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAKDALE KIDNEY CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265403976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 749157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-9157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-495-8075
Provider Business Mailing Address Fax Number:
562-495-8076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 W F ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95361-3573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-848-5780
Provider Business Practice Location Address Fax Number:
209-848-5789
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEINBERG
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
214-736-2700

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  110000477 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CDC02853F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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