Basic Information
| Provider Information | |||||||||
| NPI: | 1669436648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CALIFORNA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAVITA RENAL SPECIALISTS OF CALIFORNIA MEDICAL CORPORATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2355 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003104872 | ||||||||
| FaxNumber: | 8773284923 | ||||||||
| Practice Location | |||||||||
| Address1: | 15141 E WHITTIER BLVD | ||||||||
| Address2: | STE 225 | ||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626983536 | ||||||||
| FaxNumber: | 5626983945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GABRIEL | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | EFTHIM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT SECRETARY TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8003104872 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | GR0093980 | 05 | CA | MEDICAID |