MEDICARE: KIDNEY CENTER OF SHERMAN OAKS, 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	930000991	CA

General Provider Information

NPI Number	:	1710923677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY CENTER OF SHERMAN OAKS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 251549
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75025-1500
Country	:	US
Telephone Number	:	214-736-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	4955 VAN NUYS BLVD
Second Line	:	SUITE # 111
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403-1801
Country	:	US
Telephone Number	:	818-285-5913
Fax Number	:	818-285-5917

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

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	10/02/2021

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