Healthcare Provider Details

I. General information

NPI: 1245329184
Provider Name (Legal Business Name): MOBILE KIDNEY STONE CENTERS OF CALIFORNIA, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 CAPITAL OF TEXAS HIGHWAY SUITE B200
AUSTIN TX
78746-6574
US

IV. Provider business mailing address

PO BOX 847324
DALLAS TX
75284-7324
US

V. Phone/Fax

Practice location:
  • Phone: 512-314-4331
  • Fax: 512-314-4494
Mailing address:
  • Phone: 512-314-4331
  • Fax: 512-314-4494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QL0400X
TaxonomyLithotripsy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THERESA DAVIS
Title or Position: DIRECTOR, CBO
Credential:
Phone: 512-314-4331