=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205895869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVITA RIVERSIDE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2006
-----------------------------------------------------
Last Update Date | 12/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32291 MISSION TRL BLDG S
-----------------------------------------------------
City | LAKE ELSINORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92530-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-674-5050
-----------------------------------------------------
Fax | 951-674-5570
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L&C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, LICENSURE & CERTIFICATION
-----------------------------------------------------
Name | SAMUEL T. WEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-341-6641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | 240000841
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------