Provider Demographics
NPI:1417633355
Name:SRS-LA HABRA
Entity Type:Organization
Organization Name:SRS-LA HABRA
Other - Org Name:SRS-LA HABRA, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:S
Authorized Official - Last Name:TANNENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD
Authorized Official - Phone:615-467-0140
Mailing Address - Street 1:4230 HARDING PIKE
Mailing Address - Street 2:STE 205
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2098
Mailing Address - Country:US
Mailing Address - Phone:615-988-7881
Mailing Address - Fax:
Practice Address - Street 1:1611 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631
Practice Address - Country:US
Practice Address - Phone:615-988-7881
Practice Address - Fax:855-631-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment