Basic Information
| Provider Information | |||||||||
| NPI: | 1700858099 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN GABRIEL REGIONAL DIALYSIS TRAINING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WORLD TRADE CTR | ||||||||
| Address2: | 2500 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908310002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624958075 | ||||||||
| FaxNumber: | 5624958076 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 S ATLANTIC BLVD | ||||||||
| Address2: | 103 | ||||||||
| City: | MONTEREY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917544756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265768556 | ||||||||
| FaxNumber: | 6265768557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5624958075 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | CDC02684G | 05 | CA | MEDICAID |