Healthcare Provider Details

I. General information

NPI: 1548206402
Provider Name (Legal Business Name): KIDNEY DIALYSIS CENTER OF WEST LOS ANGELES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

2400 DALLAS PKWY SUITE 350
PLANO TX
75093-4370
US

V. Phone/Fax

Practice location:
  • Phone: 310-840-8688
  • Fax: 805-433-7655
Mailing address:
  • Phone: 214-736-2700
  • Fax: 214-735-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number930000908
License Number StateCA

VIII. Authorized Official

Name: THOMAS L. WEINBERG
Title or Position: SENIOR VICE PRESIDENT/GENERAL COUNS
Credential:
Phone: 214-736-2730