Healthcare Provider Details

I. General information

NPI: 1447383971
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: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 ATLANTIC AVE SUITE 101
LONG BEACH CA
90806-1740
US

IV. Provider business mailing address

3650 SOUTH ST SUITE 301
LAKEWOOD CA
90712-1502
US

V. Phone/Fax

Practice location:
  • Phone: 562-427-0350
  • Fax: 560-630-3107
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: SANDRA RODRIGUEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 562-630-3111