MEDICARE: DVA HEALTHCARE RENAL CARE, 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

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

General Provider Information

NPI Number	:	1013986389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DVA HEALTHCARE RENAL CARE, INC.

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	STE 400 L&C
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-320-4435
Fax Number	:	303-209-7821

Provider Business Practice Location Address
First Line	:	821 LINCOLN HWY
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2216
Country	:	US
Telephone Number	:	618-632-9550
Fax Number	:	618-632-8903

Authorized Official
Title or Position	:	GROUP VICE PRESIDENT
Name	:	THOMAS O USILTON JR.
Credential	:
Telephone Number	:	770-541-7922

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	08/22/2020

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