Healthcare Provider Details

I. General information

NPI: 1649291774
Provider Name (Legal Business Name): CALIFORNIA KIDNEY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date: 08/21/2007
Reactivation Date: 07/29/2008

III. Provider practice location address

50 MORELAND RD
SIMI VALLEY CA
93065-1659
US

IV. Provider business mailing address

PO BOX 940838
SIMI VALLEY CA
93094-0838
US

V. Phone/Fax

Practice location:
  • Phone: 805-433-7360
  • Fax: 805-306-0620
Mailing address:
  • Phone: 805-433-7777
  • Fax: 805-433-7607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF 320950
License Number StateCA

VIII. Authorized Official

Name: LILY KRASTEIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 805-433-7507