MEDICARE: HOME DIALYSIS CENTERS OF RANCHO CUCAMONGA LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720314982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME DIALYSIS CENTERS OF RANCHO CUCAMONGA LLC

Provider Business Mailing Address
First Line	:	8239 ROCHESTER AVE
Second Line	:	SUITE 110
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-0714
Country	:	US
Telephone Number	:	909-945-2104
Fax Number	:	909-945-2152

Provider Business Practice Location Address
First Line	:	8239 ROCHESTER AVE
Second Line	:	SUITE 110
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-0714
Country	:	US
Telephone Number	:	909-945-2104
Fax Number	:	909-945-2152

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MR. SHAWN MEHRABIAN
Credential	:	MSC
Telephone Number	:	818-939-2047

Provider Enumeration Date	:	10/23/2009
Last Update Date	:	04/08/2022

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