Provider Demographics
NPI:1538303342
Name:INDIAN WELLS VALLEY DIALYSIS CENTER
Entity Type:Organization
Organization Name:INDIAN WELLS VALLEY DIALYSIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:HADAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-267-7642
Mailing Address - Street 1:1643 E PALMDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4847
Mailing Address - Country:US
Mailing Address - Phone:661-267-7642
Mailing Address - Fax:
Practice Address - Street 1:212 S RICHMOND RD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-4434
Practice Address - Country:US
Practice Address - Phone:760-371-7506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment