1134189574 NPI number — DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CALIFORNIA INC

Table of content: (NPI 1134189574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134189574 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:
1134189574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX FILE #57025
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-310-4872
Provider Business Mailing Address Fax Number:
877-328-4923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 MATLOCK RD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-375-0610
Provider Business Practice Location Address Fax Number:
817-375-0640
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GABRIEL
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
EFTHIM
Authorized Official Title or Position:
OWNER PRESIDENT SECRETARY TREASURER
Authorized Official Telephone Number:
800-310-4872

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: 177068701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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