Basic Information
| Provider Information | |||||||||
| NPI: | 1144315276 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIABLO DIALYSIS ACCESS CENTER A CA PROFESSIONAL MEDICAL CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIABLO DIALYSIS ACCESS CENTER, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 EAST ST | ||||||||
| Address2: | STE 305 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945202084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256861230 | ||||||||
| FaxNumber: | 9256868443 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 EAST ST | ||||||||
| Address2: | STE 305 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945202084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256861230 | ||||||||
| FaxNumber: | 9256868443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUTTON | ||||||||
| AuthorizedOfficialFirstName: | FAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9256860315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0105450 | 05 | CA | MEDICAID |