Healthcare Provider Details

I. General information

NPI: 1437397536
Provider Name (Legal Business Name): HAWAIIAN GARDENS DIALYSIS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12191 226TH ST
HAWAIIAN GARDENS CA
90716-1510
US

IV. Provider business mailing address

5200 VIRGINIA WAY L&C DEPT
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 562-421-4016
  • Fax: 562-421-4652
Mailing address:
  • Phone: 615-341-6765
  • Fax: 833-782-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number550001463
License Number StateCA

VIII. Authorized Official

Name: JOHN D WINSTEL
Title or Position: CHIEF ACCOUNTING OFFICER
Credential:
Phone: 253-733-4501