Basic Information
| Provider Information | |||||||||
| NPI: | 1093062796 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERITONEAL DIALYSIS CENTER OF AMERICA - SAN GABRIEL, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 S ATLANTIC BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MONTEREY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917544756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265768556 | ||||||||
| FaxNumber: | 6265768557 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 S ATLANTIC BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MONTEREY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917544756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265768556 | ||||||||
| FaxNumber: | 6265768557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2012 | ||||||||
| LastUpdateDate: | 08/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9515667249 | ||||||||
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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 | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.