1013977461 NPI number — DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CALIFORNIA INC

Table of content: (NPI 1013977461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013977461 NPI number — DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CALIFORNIA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CALIFORNIA 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:
Provider Other Organization Name Type Code:
6
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:
1013977461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1360 BURTON DR
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
VACAVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95687-3557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-466-4379
Provider Business Mailing Address Fax Number:
707-446-4417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1360 BURTON DR
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
VACAVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95687-3539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-446-4379
Provider Business Practice Location Address Fax Number:
707-446-4417
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GABRIEL
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
303-626-6103

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DA5762 . This is a "RR RET BOARD MED RR CARR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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