Healthcare Provider Details

I. General information

NPI: 1134252679
Provider Name (Legal Business Name): SOUTHLAND RENAL MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18111 BROOKHURST ST STE 6700
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

3300 E SOUTH ST STE 308
LAKEWOOD CA
90805-4598
US

V. Phone/Fax

Practice location:
  • Phone: 562-630-3111
  • Fax: 562-630-3107
Mailing address:
  • Phone: 562-630-3111
  • Fax: 562-630-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA46344
License Number StateCA

VIII. Authorized Official

Name: CORA FISCHMAN
Title or Position: COO
Credential:
Phone: 562-630-3111