Provider Demographics
NPI:1558434282
Name:RAI CARE CENTERS OF SOUTHERN CALIFORNIA I, LLC
Entity Type:Organization
Organization Name:RAI CARE CENTERS OF SOUTHERN CALIFORNIA I, LLC
Other - Org Name:RAI-NORTH WATERMAN-SAN BERNADINO
Other - Org Type:Other Name
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:1500 N WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5111
Mailing Address - Country:US
Mailing Address - Phone:909-381-1591
Mailing Address - Fax:909-384-1744
Practice Address - Street 1:1500 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5111
Practice Address - Country:US
Practice Address - Phone:909-381-1591
Practice Address - Fax:909-384-1744
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-17
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC70020JMedicaid
CAZZZR0213ZOtherBLUE SHIELD OF CALIFORNIA
CA052575OtherBLUE CROSS OF CALIFORNIA
CACDC70020JMedicaid
CACDC70020JMedicaid