MEDICARE: DVA RENAL HEALTHCARE INC

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	ESRD001070	GA

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	:	1437128493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DVA RENAL HEALTHCARE INC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	LICENSURE AND CERTIFICATION DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-320-4268
Fax Number	:	877-238-0567

Provider Business Practice Location Address
First Line	:	2812 WILLIAMS ST
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31404-4134
Country	:	US
Telephone Number	:	912-354-5005
Fax Number	:	912-353-7509

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	JOHN WINSTEL
Credential	:
Telephone Number	:	253-733-4501

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	01/12/2021

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