Basic Information
| Provider Information | |||||||||
| NPI: | 1083649651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | L.A. COUNTY NEPHROLOGY ASSOCIATES A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22036 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237263868 | ||||||||
| FaxNumber: | 3237263870 | ||||||||
| Practice Location | |||||||||
| Address1: | 3114 W BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906402217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237261317 | ||||||||
| FaxNumber: | 3237263870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | MARINO | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3237263868 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0052992 | 05 | CA | MEDICAID | 00A792790 | 05 | CA | MEDICAID | ZZZ447842 | 01 | CA | BLUE SHIELD GROUP NUMBER | OTHER | C13392 | 01 | CA | RAILROAD MEDICARE GROUP | OTHER | GR0052991 | 05 | CA | MEDICAID | GR0052990 | 05 | CA | MEDICAID |