Provider Demographics
NPI:1447587126
Name:GREATER LONG BEACH VASCULAR ACCESS, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:GREATER LONG BEACH VASCULAR ACCESS, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHWAJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-867-5300
Mailing Address - Street 1:16506 LAKEWOOD BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-5164
Mailing Address - Country:US
Mailing Address - Phone:562-867-5300
Mailing Address - Fax:562-867-8666
Practice Address - Street 1:16506 LAKEWOOD BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-5164
Practice Address - Country:US
Practice Address - Phone:562-867-5300
Practice Address - Fax:562-867-8666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1447587126Medicaid
CA1447587126Medicaid