Provider Demographics
NPI:1801128301
Name:NORTHRIDGE DIALYSIS CENTER, LLC
Entity type:Organization
Organization Name:NORTHRIDGE DIALYSIS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINOD
Authorized Official - Middle Name:M
Authorized Official - Last Name:ASSOMULL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-321-5800
Mailing Address - Street 1:4000 COVER ST
Mailing Address - Street 2:STE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1790
Mailing Address - Country:US
Mailing Address - Phone:562-421-2690
Mailing Address - Fax:562-421-2060
Practice Address - Street 1:9325 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-2983
Practice Address - Country:US
Practice Address - Phone:818-993-6700
Practice Address - Fax:818-993-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001462261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1801128301Medicaid
CA552674Medicare Oscar/Certification