1871903385 NPI number — SYLMAR DIALYSIS LLC

Table of content: (NPI 1871903385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871903385 NPI number — SYLMAR DIALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYLMAR DIALYSIS 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:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871903385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2016
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:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12151 SAN FERNANDO ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLMAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91342-5003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-465-9464
Provider Business Practice Location Address Fax Number:
818-367-0340
Provider Enumeration Date:
05/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ASSOMULL
Authorized Official First Name:
VINOD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
818-321-5800

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)

  • Identifier: 1871903385 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com