Provider Demographics
NPI:1558950022
Name:INTEGRATED HOME DIALYSIS STAFF ASSISTANT LLC
Entity Type:Organization
Organization Name:INTEGRATED HOME DIALYSIS STAFF ASSISTANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:O
Authorized Official - Last Name:OBEMBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-614-8740
Mailing Address - Street 1:PO BOX 76016
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90076-0016
Mailing Address - Country:US
Mailing Address - Phone:310-614-8740
Mailing Address - Fax:
Practice Address - Street 1:1507 ROSS ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-4246
Practice Address - Country:US
Practice Address - Phone:310-614-8740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal DialysisGroup - Multi-Specialty