Healthcare Provider Details

I. General information

NPI: 1649298530
Provider Name (Legal Business Name): NEPHRON DIALYSIS CENTER OF LAKEWOOD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 DOWNEY AVENUE
LONG BEACH CA
90805-4517
US

IV. Provider business mailing address

3356 W. BALL ROAD SUITE 216
ANAHEIM CA
92804-3702
US

V. Phone/Fax

Practice location:
  • Phone: 562-663-0788
  • Fax: 562-663-0794
Mailing address:
  • Phone: 714-226-0818
  • Fax: 714-226-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number930000886
License Number StateCA

VIII. Authorized Official

Name: DR. GADSALLI RAMASWAMY RAVIKUMAR
Title or Position: PRESIDENT/CEO
Credential: M.D
Phone: 714-226-0818