Basic Information
| Provider Information | |||||||||
| NPI: | 1033151816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDNEY DIALYSIS CENTER OF SAN LUIS OBISPO,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 940838 | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930940838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054437777 | ||||||||
| FaxNumber: | 8054337655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1043 MARSH ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934013629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055431013 | ||||||||
| FaxNumber: | 8055435654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 01/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | UPPONI | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | VIRAL | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ACCOUNTS RECEIVABLE | ||||||||
| AuthorizedOfficialTelephone: | 8054337506 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | ZZZ02842Z | 01 | CA | BLUE SHIELD | OTHER | CDC02811G | 05 | CA | MEDICAID |