=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508828765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DVA RENAL HEALTHCARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2006
-----------------------------------------------------
Last Update Date | 02/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2881 BUSINESS PARK CT STE 130
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-9019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-341-9551
-----------------------------------------------------
Fax | 702-341-9379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L&C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-320-4435
-----------------------------------------------------
Fax | 303-209-7821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ACCOUNTING OFFICER
-----------------------------------------------------
Name | JAMES K HILGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-733-4500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | 2201ESR12
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------