Provider Demographics
NPI:1447285275
Name:SAN DIMAS DIALYSIS CENTER A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SAN DIMAS DIALYSIS CENTER A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOJTABA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGHADAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-542-2900
Mailing Address - Street 1:1335 W CYPRESS AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3537
Mailing Address - Country:US
Mailing Address - Phone:909-542-2777
Mailing Address - Fax:909-394-1800
Practice Address - Street 1:1335 W CYPRESS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3537
Practice Address - Country:US
Practice Address - Phone:909-542-2900
Practice Address - Fax:909-394-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000175261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55-2552Medicare ID - Type UnspecifiedESRD