Provider Demographics
NPI:1972529527
Name:SAN FERNANDO WEST KIDNEY CENTER
Entity Type:Organization
Organization Name:SAN FERNANDO WEST KIDNEY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-657-0213
Mailing Address - Street 1:7230 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE # 205
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1907
Mailing Address - Country:US
Mailing Address - Phone:818-657-0213
Mailing Address - Fax:818-657-0131
Practice Address - Street 1:7230 MEDICAL CTR
Practice Address - Street 2:SUITE# 101-102
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1907
Practice Address - Country:US
Practice Address - Phone:818-657-0213
Practice Address - Fax:818-657-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA052588261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC70036GMedicaid
CACDC70036GMedicaid