Provider Demographics
NPI:1215342175
Name:LAUREL CANYON DIALYSIS, LLC
Entity type:Organization
Organization Name:LAUREL CANYON DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PARAG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-365-1194
Mailing Address - Street 1:8987 LAUREL CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-1732
Mailing Address - Country:US
Mailing Address - Phone:818-771-9950
Mailing Address - Fax:818-771-9951
Practice Address - Street 1:8987 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-1732
Practice Address - Country:US
Practice Address - Phone:818-771-9950
Practice Address - Fax:818-771-9951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-29
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA552777261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA552777Medicare Oscar/Certification
CA55-2777Medicare PIN