Provider Demographics
NPI:1245567627
Name:MK DIALYSIS CENTER AT RIVERSIDE, INC.
Entity Type:Organization
Organization Name:MK DIALYSIS CENTER AT RIVERSIDE, INC.
Other - Org Name:VAN BUREN DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:QUTUB
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-735-1257
Mailing Address - Street 1:3595 VAN BUREN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-0311
Mailing Address - Country:US
Mailing Address - Phone:909-542-2900
Mailing Address - Fax:
Practice Address - Street 1:3595 VAN BUREN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-0311
Practice Address - Country:US
Practice Address - Phone:909-542-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2016-07-11
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
CA1245567627OtherNPI
CA1245567627OtherNPI