Basic Information
Provider Information | |||||||||
NPI: | 1558557801 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF SAN JOAQUIN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | END STAGE RENAL DISEASE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1020 | ||||||||
Address2: |   | ||||||||
City: | STOCKTON | ||||||||
State: | CA | ||||||||
PostalCode: | 952013120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094686937 | ||||||||
FaxNumber: | 2094687042 | ||||||||
Practice Location | |||||||||
Address1: | 7783 SOUTH FREEDOM ROAD | ||||||||
Address2: |   | ||||||||
City: | FRENCH CAMP | ||||||||
State: | CA | ||||||||
PostalCode: | 95231 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094686937 | ||||||||
FaxNumber: | 2094687042 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2007 | ||||||||
LastUpdateDate: | 08/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAPRE | ||||||||
AuthorizedOfficialFirstName: | SHEELA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2094686600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SAN JOAQUIN GENERAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD, FCCP, FACP | ||||||||
NPICertificationDate: | 08/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 030000087 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.