Provider Demographics
NPI:1063618296
Name:VALLEY NEPHROLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:VALLEY NEPHROLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEONOR
Authorized Official - Middle Name:Q
Authorized Official - Last Name:GARBUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-448-8481
Mailing Address - Street 1:1313 E HERNDON AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3306
Mailing Address - Country:US
Mailing Address - Phone:559-448-8481
Mailing Address - Fax:559-448-0996
Practice Address - Street 1:1313 E HERNDON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3306
Practice Address - Country:US
Practice Address - Phone:559-448-8481
Practice Address - Fax:559-448-0996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13844207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G138440Medicaid
CAG13844OtherSTATE LICENSE
CAGR0023120Medicaid
CAG13844OtherSTATE LICENSE
CAZZZ99970ZMedicare PIN
CAA39103Medicare UPIN
CA00G138440Medicaid