MEDICARE: ANTELOPE VALLEY DIALYSIS CENTER MEDICAL GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730285818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTELOPE VALLEY DIALYSIS CENTER MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	1643 E PALMDALE BLVD
Second Line	:
City	:	PALMDALE
State	:	CA
Zip	:	93550-4847
Country	:	US
Telephone Number	:	661-267-7645
Fax Number	:	661-267-6464

Provider Business Practice Location Address
First Line	:	1759 W AVENUE J # 102
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2703
Country	:	US
Telephone Number	:	661-942-6400
Fax Number	:	661-729-3985

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. GHASSAN S DAHHAN
Credential	:	M.D.
Telephone Number	:	661-267-7645

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/10/2007

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