Provider Demographics
NPI:1871129379
Name:SRS-SAN DIEGO LLC
Entity type:Organization
Organization Name:SRS-SAN DIEGO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:SEYMOUR
Authorized Official - Last Name:TANNENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:615-467-0140
Mailing Address - Street 1:PO BOX 198813
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-8813
Mailing Address - Country:US
Mailing Address - Phone:615-988-1060
Mailing Address - Fax:855-631-0206
Practice Address - Street 1:963 LANE AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3501
Practice Address - Country:US
Practice Address - Phone:855-474-7365
Practice Address - Fax:855-631-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-16
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment