Basic Information
Provider Information | |||||||||
NPI: | 1942528203 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOTAL RENAL CARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CSATF 19 PRISON DIALYSIS PROGRAM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15253 BAKE PARKWAY | ||||||||
Address2: |   | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 92618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9499306874 | ||||||||
FaxNumber: | 8666397505 | ||||||||
Practice Location | |||||||||
Address1: | 2001 HIGH ST | ||||||||
Address2: |   | ||||||||
City: | SELMA | ||||||||
State: | CA | ||||||||
PostalCode: | 936623512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5599927100 | ||||||||
FaxNumber: | 5599927299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2010 | ||||||||
LastUpdateDate: | 03/28/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLARKE | ||||||||
AuthorizedOfficialFirstName: | NICOLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ARRM | ||||||||
AuthorizedOfficialTelephone: | 9499306874 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.