Provider Demographics
NPI:1750569489
Name:BALBOA NEPHROLOGY MED GRP INC
Entity type:Organization
Organization Name:BALBOA NEPHROLOGY MED GRP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WENCESLAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-810-8000
Mailing Address - Street 1:4225 EXECUTIVE SQ STE 450
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-8411
Mailing Address - Country:US
Mailing Address - Phone:858-810-8000
Mailing Address - Fax:858-268-1911
Practice Address - Street 1:2205 ROSS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-3623
Practice Address - Country:US
Practice Address - Phone:760-353-0404
Practice Address - Fax:760-353-0392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0103520Medicaid
CAW1487AMedicare PIN