Provider Demographics
NPI:1457734741
Name:KIDNEY CARE SERVICES OF HUMBOLDT
Entity Type:Organization
Organization Name:KIDNEY CARE SERVICES OF HUMBOLDT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN AIDE
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:707-362-8769
Mailing Address - Street 1:1651 MYRTLE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1495
Mailing Address - Country:US
Mailing Address - Phone:707-599-6700
Mailing Address - Fax:888-475-8698
Practice Address - Street 1:1651 MYRTLE AVE STE C
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1495
Practice Address - Country:US
Practice Address - Phone:707-599-6700
Practice Address - Fax:888-475-8698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-04
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23313207RN0300X
261QH0100X, 261QP2300X, 332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN846580Medicaid