Provider Demographics
NPI:1033141254
Name:CENTRAL COAST KIDNEY DISEASE CENTER INC.
Entity Type:Organization
Organization Name:CENTRAL COAST KIDNEY DISEASE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MUTHIYALIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BABU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-349-0198
Mailing Address - Street 1:116 S PALISADE DR
Mailing Address - Street 2:100
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-8904
Mailing Address - Country:US
Mailing Address - Phone:805-614-0694
Mailing Address - Fax:805-349-9004
Practice Address - Street 1:2263 S. DEPOT RD.
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455
Practice Address - Country:US
Practice Address - Phone:805-349-8600
Practice Address - Fax:805-928-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC02871FMedicaid
CA052871Medicare ID - Type Unspecified