=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710085154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN CALIFORNIA KIDNEY STONE CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16400 LARK AVE STE 100
-----------------------------------------------------
City | LAS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-358-2805
-----------------------------------------------------
Fax | 408-358-2810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16400 LARK AVE STE 100
-----------------------------------------------------
City | LAS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-358-2805
-----------------------------------------------------
Fax | 408-358-2810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ALLI MOAYED
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 408-358-2805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------