Provider Demographics
NPI:1669657805
Name:MODESTO KIDNEY CENTER, LLC
Entity Type:Organization
Organization Name:MODESTO KIDNEY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-736-2700
Mailing Address - Street 1:1 WORLD TRADE CTR
Mailing Address - Street 2:STE 2500
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90831-0002
Mailing Address - Country:US
Mailing Address - Phone:562-495-8075
Mailing Address - Fax:562-495-8076
Practice Address - Street 1:305 E GRANGER AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4345
Practice Address - Country:US
Practice Address - Phone:209-574-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:U.S. RENAL CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-07
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000468261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC02783FMedicaid
CA052783Medicare Oscar/Certification