Provider Demographics
NPI:1265633747
Name:FOUNTAIN VALLEY REGIONAL DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:FOUNTAIN VALLEY REGIONAL DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GADSALLI
Authorized Official - Middle Name:RAMASWAMY
Authorized Official - Last Name:RAVIKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-226-0818
Mailing Address - Street 1:3356 W BALL RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3702
Mailing Address - Country:US
Mailing Address - Phone:714-226-0818
Mailing Address - Fax:714-226-0700
Practice Address - Street 1:17150 EUCLID AVENUE
Practice Address - Street 2:SUITE 111
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4092
Practice Address - Country:US
Practice Address - Phone:714-966-1595
Practice Address - Fax:714-966-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001163261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA552630Medicare PIN