Provider Demographics
NPI:1922181056
Name:GREATER LOS ANGELES DIALYSIS INC
Entity Type:Organization
Organization Name:GREATER LOS ANGELES DIALYSIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARINO
Authorized Official - Middle Name:B
Authorized Official - Last Name:DE PERALTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-571-4596
Mailing Address - Street 1:1840 S SAN GABRIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3930
Mailing Address - Country:US
Mailing Address - Phone:626-571-4596
Mailing Address - Fax:626-571-1706
Practice Address - Street 1:11204 RUSH ST
Practice Address - Street 2:
Practice Address - City:SOUTH EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-3551
Practice Address - Country:US
Practice Address - Phone:626-571-4596
Practice Address - Fax:626-571-1706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000865261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC02755FMedicaid
CAZZZ52324ZOtherBLUE SHIELD INSURANCE
CAZZZ52324ZOtherBLUE SHIELD INSURANCE