Provider Demographics
NPI:1568574366
Name:SAN DIEGO DIALYSIS SERVICES, INC.
Entity Type:Organization
Organization Name:SAN DIEGO DIALYSIS SERVICES, INC.
Other - Org Name:KEARNY MESA DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-402-9000
Mailing Address - Street 1:7927 OSTROW ST STE A
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7927 OSTROW ST STE A
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3604
Practice Address - Country:US
Practice Address - Phone:858-571-0232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
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
052576Medicare ID - Type Unspecified