Healthcare Provider Details

I. General information

NPI: 1740241454
Provider Name (Legal Business Name): DVA RENAL HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10887 W FLORISSANT AVE
SAINT LOUIS MO
63136-2405
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 314-524-5737
  • Fax: 314-524-5752
Mailing address:
  • Phone: 615-341-6264
  • Fax: 800-297-2925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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