Provider Demographics
NPI:1790960060
Name:MONTEBELLO ARTIFICIAL KIDNEY CENTER, LLC
Entity Type:Organization
Organization Name:MONTEBELLO ARTIFICIAL KIDNEY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:DHAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-721-9411
Mailing Address - Street 1:3404 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-1539
Mailing Address - Country:US
Mailing Address - Phone:323-728-7580
Mailing Address - Fax:323-728-7590
Practice Address - Street 1:3404 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-1539
Practice Address - Country:US
Practice Address - Phone:323-728-7580
Practice Address - Fax:323-728-7590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2010-04-28
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
CA552640Medicare Oscar/Certification