Provider Demographics
NPI:1649291774
Name:CALIFORNIA KIDNEY MEDICAL GROUP INC
Entity type:Organization
Organization Name:CALIFORNIA KIDNEY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-433-7507
Mailing Address - Street 1:PO BOX 940838
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93094-0838
Mailing Address - Country:US
Mailing Address - Phone:805-433-7777
Mailing Address - Fax:805-433-7607
Practice Address - Street 1:50 MORELAND RD
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1659
Practice Address - Country:US
Practice Address - Phone:805-433-7360
Practice Address - Fax:805-306-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2009-02-26
Deactivation Date:2007-08-21
Deactivation Code:
Reactivation Date:2008-07-29
Provider Licenses
StateLicense IDTaxonomies
CACLF 320950291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB23131FMedicaid
CA05D0923131Medicare PIN