Basic Information
| Provider Information | |||||||||
| NPI: | 1760586705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA KIDNEY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2160 | ||||||||
| Address2: | |||||||||
| City: | MOORPARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930202160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187182301 | ||||||||
| FaxNumber: | 8187182311 | ||||||||
| Practice Location | |||||||||
| Address1: | 13990 BEAR FENCE CT | ||||||||
| Address2: | |||||||||
| City: | MOORPARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930215022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187182301 | ||||||||
| FaxNumber: | 8187182311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | VAN BRUCK | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8184006396 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | GR0087560 | 05 | CA | MEDICAID |