Provider Demographics
NPI:1235157116
Name:LA PALMA DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:LA PALMA DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GADSALLI
Authorized Official - Middle Name:RAMASWAMY
Authorized Official - Last Name:RAVIKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-226-0818
Mailing Address - Street 1:3356 W BALL RD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3702
Mailing Address - Country:US
Mailing Address - Phone:714-226-0818
Mailing Address - Fax:714-226-0700
Practice Address - Street 1:5451 LA PALMA AVE
Practice Address - Street 2:SUITE 35
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1728
Practice Address - Country:US
Practice Address - Phone:714-523-5970
Practice Address - Fax:714-523-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000679261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC02627GMedicaid
CA052627Medicare PIN