Provider Demographics
NPI:1730285818
Name:ANTELOPE VALLEY DIALYSIS CENTER MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:ANTELOPE VALLEY DIALYSIS CENTER MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GHASSAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAHHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-267-7645
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:661-267-7645
Mailing Address - Fax:661-267-6464
Practice Address - Street 1:1759 W AVENUE J # 102
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2703
Practice Address - Country:US
Practice Address - Phone:661-942-6400
Practice Address - Fax:661-729-3985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-07-10
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
CAZZT11810GMedicaid
CAZZT11810GMedicaid