MEDICARE: DVA RENAL HEALTHCARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	930000911	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013981984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DVA RENAL HEALTHCARE INC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L&C DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-238-3085
Fax Number	:	800-268-9682

Provider Business Practice Location Address
First Line	:	2021 S FLOWER ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90007-1342
Country	:	US
Telephone Number	:	213-745-4222
Fax Number	:	213-749-1753

Authorized Official
Title or Position	:	SR DIR LICENSURE & CERTIFICATION
Name	:	SAMUEL T WEY
Credential	:
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	08/09/2023

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Directions to “DVA RENAL HEALTHCARE INC ” Practice Location

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