=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588628846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DVA HEALTHCARE SOUTHWEST OHIO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2006
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10600 MCKINLEY RD
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-3716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-733-8215
-----------------------------------------------------
Fax | 513-733-8293
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY ATT: L&C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, LICENSURE & CERTIFICATION
-----------------------------------------------------
Name | SAMUEL T 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 | 0171DC
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------