Basic Information
Provider Information | |||||||||
NPI: | 1457396657 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KIDNEY DIALYSIS CENTER OF CAMARILLO,LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 940838 | ||||||||
Address2: |   | ||||||||
City: | SIMI VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 930940838 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054337777 | ||||||||
FaxNumber: | 8054337655 | ||||||||
Practice Location | |||||||||
Address1: | 2438 N PONDEROSA DR | ||||||||
Address2: | SUITE # 101 | ||||||||
City: | CAMARILLO | ||||||||
State: | CA | ||||||||
PostalCode: | 930102369 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057650171 | ||||||||
FaxNumber: | 8054337655 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2006 | ||||||||
LastUpdateDate: | 01/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | UPPONI | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: | VIRAL | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF ACCOUNTS RECEIVABLE | ||||||||
AuthorizedOfficialTelephone: | 8054337506 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | CDC52551F | 05 | CA |   | MEDICAID |