1871799882 NPI number — DIALYSIS CENTER OF COLTON, A CALIFORNIA GENERAL PARTNERSHIP

Table of content: KAYLEE KIMMEL SISSON (NPI 1194451427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871799882 NPI number — DIALYSIS CENTER OF COLTON, A CALIFORNIA GENERAL PARTNERSHIP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIALYSIS CENTER OF COLTON, A CALIFORNIA GENERAL PARTNERSHIP
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:
1871799882
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:
600 N 13TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91786-4905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-430-0930
Provider Business Mailing Address Fax Number:
909-373-0428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 W C ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-1916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-430-0930
Provider Business Practice Location Address Fax Number:
909-430-0934
Provider Enumeration Date:
06/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FRIEDMAN
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
909-430-0930

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: CDC02817H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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