MEDICARE: MOBIALYSIS LLC

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

General Provider Information

NPI Number	:	1770308041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBIALYSIS LLC

Provider Business Mailing Address
First Line	:	3013 ANNITA DR
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-1302
Country	:	US
Telephone Number	:	818-846-4469
Fax Number	:

Provider Business Practice Location Address
First Line	:	3013 ANNITA DR
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-1302
Country	:	US
Telephone Number	:	818-846-4469
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	TEODULO CRUZ BONZON
Credential	:	LCSW
Telephone Number	:	818-846-4469

Provider Enumeration Date	:	11/20/2024
Last Update Date	:	11/20/2024

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