=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710998380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUEEN'S DIALYSIS UNIT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1135 S SUNSET AVE SUITE 103
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-337-4245
-----------------------------------------------------
Fax | 626-480-0761
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1335 CYPRESS STREET SUITE 207
-----------------------------------------------------
City | SAN DIMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91773-3537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-542-2900
-----------------------------------------------------
Fax | 909-592-6000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CLAUDIO H. GALLEGO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 909-542-2900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------