Provider Demographics
NPI:1073517967
Name:SOUTH VALLEY REGIONAL DIALYSIS CENTER INC
Entity Type:Organization
Organization Name:SOUTH VALLEY REGIONAL DIALYSIS CENTER INC
Other - Org Name:SOUTH VALLEY DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:VOGEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-541-7922
Mailing Address - Street 1:17815 VENTURA BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3610
Mailing Address - Country:US
Mailing Address - Phone:818-705-7219
Mailing Address - Fax:
Practice Address - Street 1:17815 VENTURA BLVD
Practice Address - Street 2:STE 100
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3600
Practice Address - Country:US
Practice Address - Phone:818-757-4520
Practice Address - Fax:818-757-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC02744FMedicare ID - Type UnspecifiedMEDICAL
CA052744Medicare ID - Type UnspecifiedLICENSE