=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790962199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALBOA NEPHROLOGY MEDICAL GROUP,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2008
-----------------------------------------------------
Last Update Date | 01/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 790 W ORANGE AVE STE B
-----------------------------------------------------
City | EL CENTRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92243-3274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-353-0404
-----------------------------------------------------
Fax | 760-353-5391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9373 HAZARD WAY STE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-810-8000
-----------------------------------------------------
Fax | 858-268-1911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACTS & CREDENTIALING
-----------------------------------------------------
Name | STEPHANIE WENCESLAO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-810-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------