Provider Demographics
NPI:1235130352
Name:PENINSULA NEPHROLOGY, INC.
Entity Type:Organization
Organization Name:PENINSULA NEPHROLOGY, INC.
Other - Org Name:SAN MATEO DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BS, MBA
Authorized Official - Phone:650-377-0200
Mailing Address - Street 1:2000 S EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1805
Mailing Address - Country:US
Mailing Address - Phone:650-377-0200
Mailing Address - Fax:650-358-3906
Practice Address - Street 1:2000 S EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1805
Practice Address - Country:US
Practice Address - Phone:650-377-0200
Practice Address - Fax:650-358-3906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
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
CACDC02819FMedicaid
CACDC02819FMedicaid