1861901191 NPI number — NORTHRIDGE KIDNEY CARE CENTER LLC

Table of content: (NPI 1861901191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861901191 NPI number — NORTHRIDGE KIDNEY CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHRIDGE KIDNEY CARE 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:
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:
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NPI Number Information

NPI Number:
1861901191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 COVER ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90808-1790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-421-2690
Provider Business Mailing Address Fax Number:
562-421-2060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19333 BUSINESS CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91324-3528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-709-9999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ASSOMULL
Authorized Official First Name:
VINOD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHAIRMAN
Authorized Official Telephone Number:
818-366-4626

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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