Provider Demographics
NPI:1932170008
Name:CANYON COUNTRY DIALYSIS CENTER, LLC
Entity Type:Organization
Organization Name:CANYON COUNTRY DIALYSIS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-421-2690
Mailing Address - Street 1:4000 COVER ST
Mailing Address - Street 2:STE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1790
Mailing Address - Country:US
Mailing Address - Phone:562-421-2690
Mailing Address - Fax:562-421-2060
Practice Address - Street 1:18520 VIA PRINCESSA
Practice Address - Street 2:BLDG C-1, SUITE A
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-8326
Practice Address - Country:US
Practice Address - Phone:661-298-5300
Practice Address - Fax:661-424-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000035261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC52547FMedicaid
CACDC52547FMedicaid