Basic Information
| Provider Information | |||||||||
| NPI: | 1265633747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNTAIN VALLEY REGIONAL DIALYSIS CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3356 W BALL RD | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928043702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142260818 | ||||||||
| FaxNumber: | 7142260700 | ||||||||
| Practice Location | |||||||||
| Address1: | 17150 EUCLID AVENUE | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149661595 | ||||||||
| FaxNumber: | 7149661555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | RAVIKUMAR | ||||||||
| AuthorizedOfficialFirstName: | GADSALLI | ||||||||
| AuthorizedOfficialMiddleName: | RAMASWAMY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7142260818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 550001163 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.