Healthcare Provider Details

I. General information

NPI: 1134740848
Provider Name (Legal Business Name): CVS-SHC KIDNEY CARE HOME DIALYSIS OF LOS ANGELES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8716 GARFIELD AVE STE 100
SOUTH GATE CA
90280-3723
US

IV. Provider business mailing address

300 SANTANA ROW STE 300
SAN JOSE CA
95128-2424
US

V. Phone/Fax

Practice location:
  • Phone: 562-674-2600
  • Fax: 562-928-9304
Mailing address:
  • Phone: 650-404-3655
  • Fax: 650-625-6007

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: KARI HOLLOWAY
Title or Position: VP
Credential:
Phone: 404-290-5964