Provider Demographics
NPI:1518902758
Name:KIDNEY DIALYSIS CENTER OF PISMO BEACH, LLC
Entity Type:Organization
Organization Name:KIDNEY DIALYSIS CENTER OF PISMO BEACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTS RECEIVABLE
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:VIRAL
Authorized Official - Last Name:UPPONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-433-7506
Mailing Address - Street 1:PO BOX 940838
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93094-0838
Mailing Address - Country:US
Mailing Address - Phone:805-433-7777
Mailing Address - Fax:805-433-7655
Practice Address - Street 1:320 JAMES WAY
Practice Address - Street 2:SUITE # 110
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2813
Practice Address - Country:US
Practice Address - Phone:805-556-0577
Practice Address - Fax:805-433-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2007-07-30
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
CACDC52556Medicaid
CA552556Medicare ID - Type UnspecifiedMEDICARE