Basic Information
| Provider Information | |||||||||
| NPI: | 1003887712 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MODESTO KIDNEY CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WORLD TRADE CTR | ||||||||
| Address2: | 2500 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908310002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624958075 | ||||||||
| FaxNumber: | 5624958076 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 E GRANGER AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095746800 | ||||||||
| FaxNumber: | 2095746808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5624958075 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | CDC02783F | 05 | CA | MEDICAID |