Provider Demographics
NPI:1114461043
Name:INTERCOMMUNITY DIALYSIS CENTER-LA MIRADA
Entity Type:Organization
Organization Name:INTERCOMMUNITY DIALYSIS CENTER-LA MIRADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:562-696-1841
Mailing Address - Street 1:PO BOX 6367
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90609-6367
Mailing Address - Country:US
Mailing Address - Phone:562-696-1841
Mailing Address - Fax:
Practice Address - Street 1:15060 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1301
Practice Address - Country:US
Practice Address - Phone:562-696-1841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment