MEDICARE: WEST COAST DIALYSIS CENTER, INC.

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		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

General Provider Information

NPI Number	:	1457323677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COAST DIALYSIS CENTER, INC.

Provider Business Mailing Address
First Line	:	1 WORLD TRADE CTR
Second Line	:	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	:	3780 KILROY AIRPORT WAY
Second Line	:	110
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2457
Country	:	US
Telephone Number	:	562-989-3010
Fax Number	:	562-989-3016

Authorized Official
Title or Position	:	SECRETARY
Name	:	MR. JERRY GREEN
Credential	:
Telephone Number	:	562-495-8075

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	08/22/2020

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