Healthcare Provider Details

I. General information

NPI: 1043271414
Provider Name (Legal Business Name): DVA HEALTHCARE RENAL CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13150 PONCE DE LEON DR
OCEAN SPRINGS MS
39564-2460
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 228-818-3201
  • Fax: 228-818-6468
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 Number
License Number State

VIII. Authorized Official

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