Basic Information
| Provider Information | |||||||||
| NPI: | 1790962199 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BALBOA NEPHROLOGY MEDICAL GROUP,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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 W ORANGE AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922433274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603530404 | ||||||||
| FaxNumber: | 7603535391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2008 | ||||||||
| 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 |
No ID Information.