Healthcare Provider Details

I. General information

NPI: 1477890291
Provider Name (Legal Business Name): INNOVATIVE DIALYSIS CENTER OF NORTHRIDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18546 ROSCOE BLVD SUITE 108
NORTHRIDGE CA
91324-4663
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 818-886-3771
  • Fax: 818-886-5734
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: 214-736-2732