Basic Information
| Provider Information | |||||||||
| NPI: | 1487699765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CALIFORNIA, INC | ||||||||
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| OtherOrganizationName: | MODESTO KIDNEY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1832 CENTRE POINT CIR | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605631438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308368724 | ||||||||
| FaxNumber: | 8665949002 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 MCHENRY AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094929301 | ||||||||
| FaxNumber: | 2094929180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GABRIEL | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3105362615 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.