Provider Demographics
NPI:1851654552
Name:COACHELLA KIDNEY INSTITUTE, LLC
Entity Type:Organization
Organization Name:COACHELLA KIDNEY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMBUR
Authorized Official - Middle Name:ERIAH
Authorized Official - Last Name:CHANDRASHEKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-347-8181
Mailing Address - Street 1:1413 SIXTH STREET
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-1711
Mailing Address - Country:US
Mailing Address - Phone:760-391-5300
Mailing Address - Fax:760-391-5800
Practice Address - Street 1:1413 SIXTH STREET
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1711
Practice Address - Country:US
Practice Address - Phone:760-391-5300
Practice Address - Fax:760-391-5800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2014-02-20
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
CA552722Medicare Oscar/Certification