1366654238 NPI number — WOODLAND NEPHROLOGY MED GRP

Table of content: (NPI 1366654238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366654238 NPI number — WOODLAND NEPHROLOGY MED GRP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODLAND NEPHROLOGY MED GRP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366654238
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 COTTONWOOD ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
WOODLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95695-3603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-668-3600
Provider Business Mailing Address Fax Number:
530-668-3601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 COTTONWOOD ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
WOODLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95695-3603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-668-3600
Provider Business Practice Location Address Fax Number:
530-668-3601
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
CINDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
530-668-3600

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G433540 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0087050 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com