Basic Information
| Provider Information | |||||||||
| NPI: | 1548231350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC SOUTH BAY DIALYSIS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | U.S. RENAL CARE PACIFIC GATEWAY DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 749160 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900749160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624958075 | ||||||||
| FaxNumber: | 5624958076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1149 W 190TH ST | ||||||||
| Address2: | STE 1004 | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902484321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109650830 | ||||||||
| FaxNumber: | 3109650839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 11/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | WEINBERG | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2147362700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | U.S. RENAL CARE, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 930000908 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | CDC02821G | 05 | CA | MEDICAID |