Healthcare Provider Details

I. General information

NPI: 1013981984
Provider Name (Legal Business Name): DVA RENAL HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 S FLOWER ST
LOS ANGELES CA
90007-1342
US

IV. Provider business mailing address

5200 VIRGINIA WAY L&C DEPT
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 213-745-4222
  • Fax: 213-749-1753
Mailing address:
  • Phone: 615-238-3085
  • Fax: 800-268-9682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number930000911
License Number StateCA

VIII. Authorized Official

Name: SAMUEL T WEY
Title or Position: SR DIR LICENSURE & CERTIFICATION
Credential:
Phone: 615-341-6641