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NPI Code Detail

MEDICARE: CANYON COUNTRY DIALYSIS CENTER, LLC

MEDICARE: CANYON COUNTRY DIALYSIS CENTER, 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
1261QE0700XEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center550000035CA

Other Identifiers

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

General Provider Information

NPI Number : 1932170008
Entity Type Code : Organization
Provider Name (Legal Business Name) : CANYON COUNTRY DIALYSIS CENTER, LLC
Provider Business Mailing Address
First Line : 4000 COVER ST
Second Line : STE 100
City : LONG BEACH
State : CA
Zip : 90808-1790
Country : US
Telephone Number : 562-421-2690
Fax Number : 562-421-2060
Provider Business Practice Location Address
First Line : 18520 VIA PRINCESSA
Second Line : BLDG C-1, SUITE A
City : CANYON COUNTRY
State : CA
Zip : 91387-8326
Country : US
Telephone Number : 661-298-5300
Fax Number : 661-424-9733
Authorized Official
Title or Position : SECRETARY
Name : MR. JERRY GREEN
Credential :
Telephone Number : 562-421-2690
Provider Enumeration Date : 01/27/2006
Last Update Date : 11/29/2016

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Directions to “CANYON COUNTRY DIALYSIS CENTER, LLC ” Practice Location

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