MEDICARE: ST. VINCENT DIALYSIS CENTER, 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	930000245	CA

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	:	1992700314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. VINCENT DIALYSIS CENTER, INC.

Provider Business Mailing Address
First Line	:	201 S ALVARADO ST
Second Line	:	STE 220
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2388
Country	:	US
Telephone Number	:	213-484-7289
Fax Number	:	213-207-5640

Provider Business Practice Location Address
First Line	:	201 S ALVARADO ST
Second Line	:	STE 220
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2388
Country	:	US
Telephone Number	:	213-484-7289
Fax Number	:	213-207-5640

Authorized Official
Title or Position	:	DIRECTOR DIALYSIS SERVICES
Name	:	ALICE M KIRCHNER
Credential	:	RN, MHA
Telephone Number	:	213-484-7289

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	02/16/2017

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