Healthcare Provider Details

I. General information

NPI: 1487625190
Provider Name (Legal Business Name): LONG BEACH DIALYSIS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ATLANTIC AVE STE 108
LONG BEACH CA
90813-3408
US

IV. Provider business mailing address

PO BOX 749146
LOS ANGELES CA
90074-9146
US

V. Phone/Fax

Practice location:
  • Phone: 562-435-3637
  • Fax: 562-435-3084
Mailing address:
  • Phone: 562-495-8075
  • Fax: 562-495-8076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number930000923
License Number StateCA

VIII. Authorized Official

Name: THOMAS L. WEINBERG
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 214-736-2700