MEDICARE: SIMI DIALYSIS CENTER, 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

General Provider Information

NPI Number	:	1205030467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMI DIALYSIS CENTER, LLC

Provider Business Mailing Address
First Line	:	1 WORLD TRADE CTR
Second Line	:	STE 2500
City	:	LONG BEACH
State	:	CA
Zip	:	90831-0002
Country	:	US
Telephone Number	:	562-495-8075
Fax Number	:	562-495-8076

Provider Business Practice Location Address
First Line	:	1407 E LOS ANGELES AVE
Second Line	:	STE G & H
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-2863
Country	:	US
Telephone Number	:	562-495-8075
Fax Number	:	562-495-8076

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	THOMAS L. WEINBERG
Credential	:
Telephone Number	:	214-736-2700

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	11/14/2014

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