Healthcare Provider Details

I. General information

NPI: 1518016773
Provider Name (Legal Business Name): KIDNEY CENTER A MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3543 SAN DIMAS ST SUITE B
BAKERSFIELD CA
93301-1605
US

IV. Provider business mailing address

PO BOX 11959
BAKERSFIELD CA
93389-3959
US

V. Phone/Fax

Practice location:
  • Phone: 661-869-2600
  • Fax: 661-869-2003
Mailing address:
  • Phone: 661-869-2600
  • Fax: 661-869-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberG75701
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberG75701
License Number StateCA

VIII. Authorized Official

Name: CAROLINE WONG
Title or Position: OWNER OPERATOR
Credential: MD
Phone: 661-869-2600