Healthcare Provider Details

I. General information

NPI: 1154668986
Provider Name (Legal Business Name): INNOVATIVE DIALYSIS CENTER OF WEST LOS ANGELES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S LA CIENEGA BLVD SUITE 100
LOS ANGELES CA
90035-4641
US

IV. Provider business mailing address

1 WORLD TRADE CTR STE 2500
LONG BEACH CA
90831-0002
US

V. Phone/Fax

Practice location:
  • Phone: 310-840-5688
  • Fax: 310-840-5690
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 Number
License Number State

VIII. Authorized Official

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