Provider Demographics
NPI:1154668986
Name:INNOVATIVE DIALYSIS CENTER OF WEST LOS ANGELES, LLC
Entity Type:Organization
Organization Name:INNOVATIVE DIALYSIS CENTER OF WEST LOS ANGELES, LLC
Other - Org Name:U.S. RENAL CARE WEST LOS ANGELES DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-736-2700
Mailing Address - Street 1:1 WORLD TRADE CTR
Mailing Address - Street 2:STE 2500
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90831-0002
Mailing Address - Country:US
Mailing Address - Phone:562-495-8075
Mailing Address - Fax:562-495-8076
Practice Address - Street 1:1801 S LA CIENEGA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-4641
Practice Address - Country:US
Practice Address - Phone:310-840-5688
Practice Address - Fax:310-840-5690
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:U.S. RENAL CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-14
Last Update Date:2013-10-28
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
CA052809Medicare Oscar/Certification