1992131395 NPI number — INNOVATIVE DIALYSIS CENTERS OF LA JOLLA LLC

Table of content: (NPI 1992131395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992131395 NPI number — INNOVATIVE DIALYSIS CENTERS OF LA JOLLA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE DIALYSIS CENTERS OF LA JOLLA 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:
1992131395
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 WORLD TRADE CTR STE 2500
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:
90831-2500
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:
2084 OTAY LAKES RD
Provider Second Line Business Practice Location Address:
STE 101-A
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91915-1368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-397-0262
Provider Business Practice Location Address Fax Number:
619-482-6791
Provider Enumeration Date:
09/18/2013

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

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





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