Healthcare Provider Details

I. General information

NPI: 1770618571
Provider Name (Legal Business Name): LOMPOC ARTIFICIAL KIDNEY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 W PINE AVE
LOMPOC CA
93436-4023
US

IV. Provider business mailing address

1704 STATE ST
SANTA BARBARA CA
93101-2522
US

V. Phone/Fax

Practice location:
  • Phone: 805-563-0090
  • Fax: 805-563-2643
Mailing address:
  • Phone: 805-563-0090
  • Fax: 805-563-2643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number080000674
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCDC02838F
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name: MRS. JUANA MURILLO
Title or Position: BILLING COORDINATOR
Credential:
Phone: 805-563-0090