Provider Demographics
NPI:1518166594
Name:STOCKTON KIDNEY CLINIC, LLC
Entity Type:Organization
Organization Name:STOCKTON KIDNEY CLINIC, LLC
Other - Org Name:STOCKTON KIDNEY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-472-3300
Mailing Address - Street 1:1523 E MARCH LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210
Mailing Address - Country:US
Mailing Address - Phone:209-472-3300
Mailing Address - Fax:209-472-0900
Practice Address - Street 1:1523 E MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210
Practice Address - Country:US
Practice Address - Phone:209-472-3300
Practice Address - Fax:209-472-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QE0700X261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment