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General NPI Number Information
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NPI Number | 1306848569
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Entity Type | Organization
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Legal Business Name | MODESTO KIDNEY MEDICAL GROUP
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Dates
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Enumeration Date | 06/01/2005
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Last Update Date | 03/29/2013
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Provider Practice Location Address
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Address Line | 305 E GRANGER AVE STE 202
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City | MODESTO
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State | CA
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Zip | 95350-4344
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Country | US
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Telephone | 209-526-1606
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Fax | 209-526-1677
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Provider Business Mailing Address
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Address Line | 305 E GRANGER AVE SUITE 202
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City | MODESTO
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State | CA
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Zip | 95350-4345
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Country | US
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Telephone | 209-526-1606
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Fax | 209-526-1677
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | LORI D MEISCHKE
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Credential |
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Telephone | 541-706-9073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 01031187 02
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License Number State | CA
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