Basic Information
| Provider Information | |||||||||
| NPI: | 1023070273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAUKERT DIALYSIS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NAPA VALLEY COMMUNITY DIALYSIS CENTER INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 TRANCAS ST | ||||||||
| Address2: | SUITE #267 | ||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072246533 | ||||||||
| FaxNumber: | 7072246535 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 TRANCAS ST | ||||||||
| Address2: | SUITE #267 | ||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072246533 | ||||||||
| FaxNumber: | 7072246535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PAUKERT | ||||||||
| AuthorizedOfficialFirstName: | SHERYLE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7072246533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN NP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | ZZZ47696Z | 01 | CA | BLUE SHIELD PROVIDER ID | OTHER | 1764 | 01 | CA | PHC | OTHER | CDC70009F | 05 | CA | MEDICAID |