MEDICARE: MORENO VALLEY REGIONAL DIALYSIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	240000808	CA

General Provider Information

NPI Number	:	1740474683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORENO VALLEY REGIONAL DIALYSIS

Provider Business Mailing Address
First Line	:	3356 W BALL RD
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-3702
Country	:	US
Telephone Number	:	714-226-0818
Fax Number	:	714-226-0700

Provider Business Practice Location Address
First Line	:	22620 GOLDENCREST DRIVE
Second Line	:	SUITE 101
City	:	MORENO VALLEY
State	:	CA
Zip	:	92553-9032
Country	:	US
Telephone Number	:	951-656-3804
Fax Number	:	951-656-7508

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. GADSALLI RAMASWAMY RAVIKUMAR
Credential	:	M.D
Telephone Number	:	714-226-0818

Provider Enumeration Date	:	09/04/2007
Last Update Date	:	11/27/2012

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