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General NPI Number Information
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NPI Number | 1366410417
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Entity Type | Organization
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Legal Business Name | DVA HEALTHCARE RENAL CARE INC
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Dates
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Enumeration Date | 03/14/2006
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Last Update Date | 04/23/2025
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Provider Practice Location Address
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Address Line | 2704 N OAK ST BLDG H
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City | VALDOSTA
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State | GA
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Zip | 31602-1723
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Country | US
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Telephone | 229-247-4857
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Fax | 229-245-8658
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Provider Business Mailing Address
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Address Line | 5200 VIRGINIA WAY L&C DEPT
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City | BRENTWOOD
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State | TN
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Zip | 37027-7569
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP LICENSURE & CERTIFICATION
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Name | SAMUEL T WEY
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Credential |
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Telephone | 615-341-6641
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | ESRD001147
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License Number State | GA
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