Healthcare Provider Details

I. General information

NPI: 1033141254
Provider Name (Legal Business Name): CENTRAL COAST KIDNEY DISEASE CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2263 S. DEPOT RD.
SANTA MARIA CA
93455
US

IV. Provider business mailing address

116 S PALISADE DR 100
SANTA MARIA CA
93454-8904
US

V. Phone/Fax

Practice location:
  • Phone: 805-349-8600
  • Fax: 805-928-5145
Mailing address:
  • Phone: 805-614-0694
  • Fax: 805-349-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MUTHIYALIAH BABU
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 805-349-0198