Healthcare Provider Details

I. General information

NPI: 1083726871
Provider Name (Legal Business Name): CALIFORNIA KIDNEY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date: 08/21/2007
Reactivation Date: 07/29/2008

III. Provider practice location address

227 W JANSS RD SUITE 110
THOUSAND OAKS CA
91360-1848
US

IV. Provider business mailing address

PO BOX 940838
SIMI VALLEY CA
93094-0838
US

V. Phone/Fax

Practice location:
  • Phone: 805-496-6051
  • Fax: 805-496-6785
Mailing address:
  • Phone: 805-433-7777
  • Fax: 805-433-7607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: LILY KRASTEIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 805-433-7777