Basic Information
| Provider Information | |||||||||
| NPI: | 1750569489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BALBOA NEPHROLOGY MED GRP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 EXECUTIVE SQ STE 450 | ||||||||
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| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920378411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588108000 | ||||||||
| FaxNumber: | 8582681911 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 ROSS AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922433623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603530404 | ||||||||
| FaxNumber: | 7603530392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | WENCESLAO | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACTS & CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8588108000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | GR0103520 | 05 | CA | MEDICAID |