Provider Demographics
NPI:1407897358
Name:SAN JOAQUIN KIDNEY CLINIC, INC
Entity Type:Organization
Organization Name:SAN JOAQUIN KIDNEY CLINIC, INC
Other - Org Name:SAN JOAQUIN KIDNEY CLINIC, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:P.
Authorized Official - Middle Name:B
Authorized Official - Last Name:SAGIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:209-546-1868
Mailing Address - Street 1:1801 E MARCH LN # B-265
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6629
Mailing Address - Country:US
Mailing Address - Phone:209-546-1868
Mailing Address - Fax:209-461-6505
Practice Address - Street 1:1801 E MARCH LN # B-265
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-546-1868
Practice Address - Fax:209-461-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73135174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A731351Medicaid
CADA0971OtherRAILROAD MEDICARE
CA00A731352Medicare PIN
CAZZZ01691ZMedicare ID - Type Unspecified
CAG64782Medicare UPIN