MEDICARE: KIDNEY DIALYSIS CENTER OF NORTHRIDGE,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	930000303	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	ZZZR0129Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1134164700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY DIALYSIS CENTER OF NORTHRIDGE,LLC

Provider Business Mailing Address
First Line	:	2400 DALLAS PKWY
Second Line	:	SUITE 350
City	:	PLANO
State	:	TX
Zip	:	75093-4370
Country	:	US
Telephone Number	:	214-736-2700
Fax Number	:	214-736-2701

Provider Business Practice Location Address
First Line	:	18546 ROSCOE BLVD
Second Line	:	SUITE # 108
City	:	NORTHRIDGE
State	:	CA
Zip	:	91324-4663
Country	:	US
Telephone Number	:	818-886-3771
Fax Number	:	818-886-5734

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

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	11/25/2013

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