Provider Demographics
NPI:1225460264
Name:JAMBOOR MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JAMBOOR MEDICAL CORPORATION
Other - Org Name:DESERT CITIES DIALYSIS-AMETHYST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHANKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-241-8063
Mailing Address - Street 1:12675 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5878
Mailing Address - Country:US
Mailing Address - Phone:760-241-8063
Mailing Address - Fax:760-241-5037
Practice Address - Street 1:11883 AMETHYST RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-9224
Practice Address - Country:US
Practice Address - Phone:760-241-8063
Practice Address - Fax:760-241-5037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-01
Last Update Date:2022-04-27
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
CA552770Medicare Oscar/Certification