Healthcare Provider Details

I. General information

NPI: 1447587126
Provider Name (Legal Business Name): GREATER LONG BEACH VASCULAR ACCESS, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16506 LAKEWOOD BLVD SUITE 200
BELLFLOWER CA
90706-5164
US

IV. Provider business mailing address

16506 LAKEWOOD BLVD SUITE 200
BELLFLOWER CA
90706-5164
US

V. Phone/Fax

Practice location:
  • Phone: 562-867-5300
  • Fax: 562-867-8666
Mailing address:
  • Phone: 562-867-5300
  • Fax: 562-867-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMIA KHWAJA
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 562-867-5300