Petra Dialysis LLC

Primary specialty

End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X

Legal business name

PETRA DIALYSIS LLC

Doing business as

Indio Dialysis

Practice address

82900 Avenue 42
Ste E
Indio, CA 92203-9658

Phone

(760) 342-6842

Fax

(760) 342-6807

NPI assigned

Nov 1, 2016

Organization subpart

No

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

Addresses

Other identifiers 1

Other names 1

• Indio Dialysis Doing business as

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Listed as

DaVita Indio DialysisCCN 552860

Overall star rating

4.0 of 5

Ownership

Profit

Certified

Feb 4, 2019

Medicare certification status

ActiveFrom the Provider of Services file

Chain

DaVita

Dialysis stations

37

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

CLIA laboratory certificates

Member of 1

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

• Total Renal Care Inc

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Burlington, WA
  • NPI 1932595584

  Member Of

  NPD member

Locations

Affiliated clinicians 2

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

• Ian David Kaiser, M.D.

  • Nephrology Physician
  • Indio, CA
  • NPI 1205279791

  Dialysis facility

  Care Compare affiliation Name & address match
• Carrie R Minnelli, MD

  • Nephrology Physician
  • Palm Springs, CA
  • NPI 1518299411

  Dialysis facility

  Care Compare affiliation Name & address match

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

{
    "created_epoch": "1477958400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715299200000",
    "number": "1710439187",
    "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",
            "telephone_number": "615-238-3085",
            "fax_number": "800-268-9682"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "82900 AVENUE 42",
            "address_2": "STE E",
            "city": "INDIO",
            "state": "CA",
            "postal_code": "922039658",
            "telephone_number": "760-342-6842",
            "fax_number": "760-342-6807"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETRA DIALYSIS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-11-01",
        "last_updated": "2024-05-10",
        "certification_date": "2024-05-10",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1710439187",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Indio Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Indio Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Tammy Perry
• Richard Byron Person, PA-C
• Rosie I Pescador, LMFT85657
• Eddie Pesqueda
• Carissa Erin Peterson, LMFT
• Aldo Pettiford
• Christine Pham
• Luyen Pham, DPM
• Twain Pham, RPH
• Thu My Phan, LCSW

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Indio, CA
• Providers in Indio, CA by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 10, 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.