NPIMap

Organization Active NPI

Davita Riverside LLC

Doing business as Lake Elsinore Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Lake Elsinore, CA
National Provider Identifier
1205895869
Registry record updated Dec 24, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
License
240000841 Issued in CA
Legal business name
DAVITA RIVERSIDE LLC
Doing business as
Lake Elsinore Dialysis
Practice address
32291 Mission TRL
BLDG S
Lake Elsinore, CA 92530-2310
Phone
(951) 674-5050
Fax
(951) 674-5570
NPI assigned
Mar 22, 2006
Last updated
Dec 24, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 24, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Samuel T. Wey
Title
VP, Licensure & Certification
Phone
(615) 341-6641

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X 240000841 CA Primary

Addresses

Primary practice location

32291 Mission TRL
BLDG S
Lake Elsinore, CA 92530-2310

Mailing address

5200 Virginia Way
L&C Dept
Brentwood, TN 37027-7569

Other identifiers 1

IdentifierTypeStateIssuer
1205895869MedicaidCA

Other names 1

  • Lake Elsinore Dialysis Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030703000011 CA Part A Provider - End-Stage Renal Disease Facility (ESRD) 7810807732 Practice locations: Lake Elsinore, CA

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Lake Elsinore DialysisCCN 052895
Overall star rating
4.0 of 5
Ownership
Profit
Certified
Nov 18, 2002
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
18

Name & address match This facility record has no NPI; it was connected to this NPI by matching name and address.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D1000652Lake Elsinore Dialysis Center32291 Mission Trail Rd BLDG S, Lake Elsinore, CA 92530Certificate of waiverJun 18, 2028

National Provider Directory

National Provider Directory
Tax ID family
Davita Riverside LLC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Practitioners & affiliated clinicians

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1142985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1734998400000",
    "number": "1205895869",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "L&C DEPT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370277569"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "32291 MISSION TRL",
            "address_2": "BLDG S",
            "city": "LAKE ELSINORE",
            "state": "CA",
            "postal_code": "925302310",
            "telephone_number": "951-674-5050",
            "fax_number": "951-674-5570"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DAVITA RIVERSIDE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-22",
        "last_updated": "2024-12-24",
        "certification_date": "2024-12-24",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_middle_name": "T.",
        "authorized_official_title_or_position": "VP, LICENSURE & CERTIFICATION",
        "authorized_official_telephone_number": "615-341-6641"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": "CA",
            "license": "240000841",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1205895869",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Elsinore Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Lake Elsinore Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Elsinore, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 24, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.