1023070273 NPI number — PAUKERT DIALYSIS INC

Table of content: (NPI 1023070273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023070273 NPI number — PAUKERT DIALYSIS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUKERT DIALYSIS INC
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:
NAPA VALLEY COMMUNITY DIALYSIS CENTER INC
Provider Other Organization Name Type Code:
3
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:
1023070273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 TRANCAS ST
Provider Second Line Business Mailing Address:
SUITE #267
Provider Business Mailing Address City Name:
NAPA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-224-6533
Provider Business Mailing Address Fax Number:
707-224-6535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 TRANCAS ST
Provider Second Line Business Practice Location Address:
SUITE #267
Provider Business Practice Location Address City Name:
NAPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-224-6533
Provider Business Practice Location Address Fax Number:
707-224-6535
Provider Enumeration Date:
04/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PAUKERT
Authorized Official First Name:
SHERYLE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER ADMINISTRATOR
Authorized Official Telephone Number:
707-224-6533

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ47696Z . This is a "BLUE SHIELD PROVIDER ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1764 . This is a "PHC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CDC70009F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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