Healthcare Provider Details

I. General information

NPI: 1932170008
Provider Name (Legal Business Name): CANYON COUNTRY DIALYSIS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18520 VIA PRINCESSA BLDG C-1, SUITE A
CANYON COUNTRY CA
91387-8326
US

IV. Provider business mailing address

4000 COVER ST STE 100
LONG BEACH CA
90808-1790
US

V. Phone/Fax

Practice location:
  • Phone: 661-298-5300
  • Fax: 661-424-9733
Mailing address:
  • Phone: 562-421-2690
  • Fax: 562-421-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number550000035
License Number StateCA

VIII. Authorized Official

Name: MR. JERRY GREEN
Title or Position: SECRETARY
Credential:
Phone: 562-421-2690