Provider Demographics
NPI:1093062796
Name:PERITONEAL DIALYSIS CENTER OF AMERICA - SAN GABRIEL, PC
Entity Type:Organization
Organization Name:PERITONEAL DIALYSIS CENTER OF AMERICA - SAN GABRIEL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRADIP
Authorized Official - Middle Name:CP
Authorized Official - Last Name:CHOWDHURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-371-4182
Mailing Address - Street 1:809 S ATLANTIC BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4756
Mailing Address - Country:US
Mailing Address - Phone:626-576-8556
Mailing Address - Fax:626-576-8557
Practice Address - Street 1:809 S ATLANTIC BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4756
Practice Address - Country:US
Practice Address - Phone:626-576-8556
Practice Address - Fax:626-576-8557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093062796Medicaid