Provider Demographics
NPI:1730190331
Name:LA PUENTE DIALYSIS CENTER, INC.
Entity type:Organization
Organization Name:LA PUENTE DIALYSIS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED ARIF
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:RIZVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-542-2900
Mailing Address - Street 1:1335 CYPRESS STREET
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:909-542-2900
Mailing Address - Fax:909-592-6000
Practice Address - Street 1:14557 TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-3492
Practice Address - Country:US
Practice Address - Phone:626-917-1719
Practice Address - Fax:626-917-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000458261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-2710Medicare PIN