Basic Information
Provider Information | |||||||||
NPI: | 1740474683 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MORENO VALLEY REGIONAL DIALYSIS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3356 W BALL RD | ||||||||
Address2: |   | ||||||||
City: | ANAHEIM | ||||||||
State: | CA | ||||||||
PostalCode: | 928043702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7142260818 | ||||||||
FaxNumber: | 7142260700 | ||||||||
Practice Location | |||||||||
Address1: | 22620 GOLDENCREST DRIVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | MORENO VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 925539032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516563804 | ||||||||
FaxNumber: | 9516567508 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/04/2007 | ||||||||
LastUpdateDate: | 11/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAVIKUMAR | ||||||||
AuthorizedOfficialFirstName: | GADSALLI | ||||||||
AuthorizedOfficialMiddleName: | RAMASWAMY | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 7142260818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 240000808 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.