Healthcare Provider Details

I. General information

NPI: 1447212451
Provider Name (Legal Business Name): DVA HEALTHCARE RENAL CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N F R HUFF DR
ST MATTHEWS SC
29135-9596
US

IV. Provider business mailing address

5200 VIRGINIA WAY STE. 400 L&C
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 803-655-7758
  • Fax: 803-655-7764
Mailing address:
  • Phone: 615-320-4218
  • Fax: 303-209-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberERD066
License Number StateSC

VIII. Authorized Official

Name: THOMAS O USILTON JR.
Title or Position: GROUP VICE PRESIDENT
Credential:
Phone: 770-541-7922