1780907600 NPI number — PENINSULA DIALYSIS ACCESS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780907600 NPI number — PENINSULA DIALYSIS ACCESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA DIALYSIS ACCESS, LLC
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:
1780907600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
864 S WOODLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92869-5229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-404-6855
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 WESTBOROUGH BLVD
Provider Second Line Business Practice Location Address:
STE. 2010
Provider Business Practice Location Address City Name:
SOUTH SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94080-3162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-871-2449
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JANSEN
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
714-404-6855

Provider Taxonomy Codes

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

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





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