Provider Demographics
NPI:1275158487
Name:CUDAHY PERITONEAL DIALYSIS CENTER
Entity Type:Organization
Organization Name:CUDAHY PERITONEAL DIALYSIS CENTER
Other - Org Name:CUDAHY PERITONEAL DIALYSIS CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-749-5360
Mailing Address - Street 1:4566 FLORENCE AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:CA
Mailing Address - Zip Code:90201-4346
Mailing Address - Country:US
Mailing Address - Phone:323-749-5360
Mailing Address - Fax:
Practice Address - Street 1:4566 FLORENCE AVE STE 3
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:CA
Practice Address - Zip Code:90201-4346
Practice Address - Country:US
Practice Address - Phone:323-749-5360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-12
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment