Provider Demographics
NPI:1992922256
Name:DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CA, INC.
Entity type:Organization
Organization Name:DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PRACTICE OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACCUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-375-0610
Mailing Address - Street 1:3030 MATLOCK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2935
Mailing Address - Country:US
Mailing Address - Phone:817-375-0610
Mailing Address - Fax:817-375-0640
Practice Address - Street 1:3030 MATLOCK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2935
Practice Address - Country:US
Practice Address - Phone:817-375-0610
Practice Address - Fax:817-375-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0484Medicare UPIN
TX8F0485Medicare UPIN
TX8F0487Medicare UPIN
TX8F0486Medicare UPIN