Healthcare Provider Details

I. General information

NPI: 1679549273
Provider Name (Legal Business Name): DVA HEALTHCARE OF NEW LONDON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SHAWS CV STE 100
NEW LONDON CT
06320-4974
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 860-701-1357
  • Fax: 860-444-0802
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number0255
License Number StateCT

VIII. Authorized Official

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