Provider Demographics
NPI:1992131395
Name:INNOVATIVE DIALYSIS CENTERS OF LA JOLLA LLC
Entity type:Organization
Organization Name:INNOVATIVE DIALYSIS CENTERS OF LA JOLLA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-736-2700
Mailing Address - Street 1:1 WORLD TRADE CTR STE 2500
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90831-2500
Mailing Address - Country:US
Mailing Address - Phone:562-495-8075
Mailing Address - Fax:562-495-8076
Practice Address - Street 1:2084 OTAY LAKES RD
Practice Address - Street 2:STE 101-A
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-1368
Practice Address - Country:US
Practice Address - Phone:619-397-0262
Practice Address - Fax:619-482-6791
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:U.S. RENAL CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-18
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA552762Medicare Oscar/Certification