Basic Information
| Provider Information | |||||||||
| NPI: | 1659537835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA KIDNEY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 940838 | ||||||||
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| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930940838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054337507 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18546 ROSCOE BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913244663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188863773 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 08/06/2008 | ||||||||
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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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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | G83840 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.