=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063014686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC KIDNEY CARE CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2020
-----------------------------------------------------
Last Update Date | 11/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 243 GREEN VALLEY RD STE A
-----------------------------------------------------
City | FREEDOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95019-3133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-672-1141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 243 GREEN VALLEY RD STE A
-----------------------------------------------------
City | FREEDOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95019-3133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-672-1141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN OWNER
-----------------------------------------------------
Name | DR. TAURINO NUNEZ AVELAR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 702-672-1141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------