Healthcare Provider Details

I. General information

NPI: 1093780017
Provider Name (Legal Business Name): DVA RENAL HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 GATEWAY CENTER WAY STE 101
SAN DIEGO CA
92102-4550
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 619-262-1960
  • Fax: 619-262-2420
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 Number080000705
License Number StateCA

VIII. Authorized Official

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