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General NPI Number Information
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NPI Number | 1518929546
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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 | 04/05/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 1134 KINCAID BRIDGE RD STE A
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City | WINNSBORO
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State | SC
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Zip | 29180-7116
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Country | US
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Telephone | 803-635-6096
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Fax | 803-635-6132
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Provider Business Mailing Address
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Address Line | 5200 VIRGINIA WAY STE. 400 L&C
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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 | 615-320-4218
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Fax | 303-209-7825
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Authorized Official
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Title or Position | GROUP VICE PRESIDENT
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Name | THOMAS O USILTON JR.
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Credential |
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Telephone | 770-541-7922
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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 | ERD063
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License Number State | SC
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