Healthcare Provider Details

I. General information

NPI: 1457734741
Provider Name (Legal Business Name): KIDNEY CARE SERVICES OF HUMBOLDT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2015
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 MYRTLE AVE STE C
EUREKA CA
95501-1495
US

IV. Provider business mailing address

1651 MYRTLE AVE STE C
EUREKA CA
95501-1495
US

V. Phone/Fax

Practice location:
  • Phone: 707-599-6700
  • Fax: 888-475-8698
Mailing address:
  • Phone: 707-599-6700
  • Fax: 888-475-8698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number23313
License Number StateCA

VIII. Authorized Official

Name: JAMES LEE WYNN JR.
Title or Position: ADMIN AIDE
Credential:
Phone: 707-599-6700