1750569489 NPI number — BALBOA NEPHROLOGY MED GRP INC

Table of content: (NPI 1750569489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750569489 NPI number — BALBOA NEPHROLOGY MED GRP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALBOA NEPHROLOGY MED GRP 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:
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:
1750569489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4225 EXECUTIVE SQ STE 450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-8411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-810-8000
Provider Business Mailing Address Fax Number:
858-268-1911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2205 ROSS AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-3623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-353-0404
Provider Business Practice Location Address Fax Number:
760-353-0392
Provider Enumeration Date:
02/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WENCESLAO
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACTS & CREDENTIALING
Authorized Official Telephone Number:
858-810-8000

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , 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: GR0103520 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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