Basic Information
| Provider Information | |||||||||
| NPI: | 1649291774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA KIDNEY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 940838 | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930940838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054337777 | ||||||||
| FaxNumber: | 8054337607 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 MORELAND RD | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930651659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054337360 | ||||||||
| FaxNumber: | 8053060620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 02/26/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/21/2007 | ||||||||
| NPIReactivationDate: | 07/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | KRASTEIN | ||||||||
| AuthorizedOfficialFirstName: | LILY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8054337507 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | CLF 320950 | CA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | LAB23131F | 05 | CA | MEDICAID |