=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104217918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAVIOTA DIALYSIS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2015
-----------------------------------------------------
Last Update Date | 02/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 DELTONA BLVD STE 26
-----------------------------------------------------
City | DELTONA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32725-6389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-574-0225
-----------------------------------------------------
Fax | 386-574-6460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L&C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, LICENSURE & CERTIFICATION
-----------------------------------------------------
Name | SAMUEL WEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-341-6641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------