MEDICARE: KIDNEY CENTER OF LOS ANGELES, 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	930000987	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	:	1982675682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY CENTER OF LOS ANGELES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 251549
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75025-1500
Country	:	US
Telephone Number	:	239-791-1747
Fax Number	:	562-495-8076

Provider Business Practice Location Address
First Line	:	2100 W 3RD ST STE 105&110
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-1944
Country	:	US
Telephone Number	:	213-481-3041
Fax Number	:	213-481-3044

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	11/17/2021

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