Provider Demographics
NPI:1720314982
Name:HOME DIALYSIS CENTERS OF RANCHO CUCAMONGA LLC
Entity Type:Organization
Organization Name:HOME DIALYSIS CENTERS OF RANCHO CUCAMONGA LLC
Other - Org Name:HOME DIALYSIS CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHRABIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSC
Authorized Official - Phone:818-939-2047
Mailing Address - Street 1:8239 ROCHESTER AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0714
Mailing Address - Country:US
Mailing Address - Phone:909-945-2104
Mailing Address - Fax:909-945-2152
Practice Address - Street 1:8239 ROCHESTER AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0714
Practice Address - Country:US
Practice Address - Phone:909-945-2104
Practice Address - Fax:909-945-2152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2022-04-08
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
CA1720314982Medicaid
CA552675Medicare Oscar/Certification