Provider Demographics
NPI:1003887712
Name:MODESTO KIDNEY CENTER, INC.
Entity Type:Organization
Organization Name:MODESTO KIDNEY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-495-8075
Mailing Address - Street 1:1 WORLD TRADE CTR
Mailing Address - Street 2:2500
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90831-0002
Mailing Address - Country:US
Mailing Address - Phone:562-495-8075
Mailing Address - Fax:562-495-8076
Practice Address - Street 1:305 E GRANGER AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4345
Practice Address - Country:US
Practice Address - Phone:209-574-6800
Practice Address - Fax:209-574-6808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC02783FMedicaid
CA52783Medicare ID - Type Unspecified