Provider Demographics
NPI:1780676957
Name:FLORENCE DIALYSIS CENTER
Entity Type:Organization
Organization Name:FLORENCE DIALYSIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MALCOM
Authorized Official - Middle Name:
Authorized Official - Last Name:EYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-598-2173
Mailing Address - Street 1:3810 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3302
Mailing Address - Country:US
Mailing Address - Phone:562-598-9399
Mailing Address - Fax:
Practice Address - Street 1:351 W FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1808
Practice Address - Country:US
Practice Address - Phone:323-789-5690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC02872FMedicaid
CA052872Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER