Organization
GREATER LOS ANGELES DIALYSIS INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARINO B DE PERALTA (VICE PRESIDENT/CFO)
(626) 571-4596
Entity
Organization
Contact information
Practice address
11204 RUSH ST, SOUTH EL MONTE, CA 91733-3551
(626) 571-4596
(626) 571-1706
Mailing address
1840 S SAN GABRIEL BLVD, SAN GABRIEL, CA 91776-3930
(626) 571-4596
(626) 571-1706
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
930000865
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
CDC02755F
—
CA
01
—
ZZZ52324Z
BLUE SHIELD INSURANCE
CA
Enumeration date
10/23/2006
Last updated
06/30/2009
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