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General NPI Number Information
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NPI Number | 1659537835
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Entity Type | Organization
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Legal Business Name | CALIFORNIA KIDNEY MEDICAL GROUP INC
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Dates
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Enumeration Date | 08/06/2008
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Last Update Date | 08/06/2008
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Provider Practice Location Address
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Address Line | 18546 ROSCOE BLVD SUITE 120
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City | NORTHRIDGE
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State | CA
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Zip | 91324-4663
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Country | US
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Telephone | 818-886-3773
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 940838
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City | SIMI VALLEY
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State | CA
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Zip | 93094-0838
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Country | US
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Telephone | 805-433-7507
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. LILY KRASTEIN
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Credential |
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Telephone | 805-433-7507
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | G83840
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License Number State | CA
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