Provider Demographics
NPI:1790158921
Name:LOS ANGELES KIDNEY CENTER, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LOS ANGELES KIDNEY CENTER, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ARDAVAN
Authorized Official - Middle Name:YAGHOUB
Authorized Official - Last Name:MASHHADIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-927-5807
Mailing Address - Street 1:1127 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-3901
Mailing Address - Country:US
Mailing Address - Phone:310-927-5807
Mailing Address - Fax:
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:SUITE 510
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3901
Practice Address - Country:US
Practice Address - Phone:310-927-5807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11899207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty