Provider Demographics
NPI:1003396615
Name:TRICITY RIVERSIDE DIALYSIS
Entity type:Organization
Organization Name:TRICITY RIVERSIDE DIALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:QUTUB
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-343-1978
Mailing Address - Street 1:3595 VAN BUREN BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-0311
Mailing Address - Country:US
Mailing Address - Phone:951-343-1978
Mailing Address - Fax:
Practice Address - Street 1:7275 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-4543
Practice Address - Country:US
Practice Address - Phone:951-343-1978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-14
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment