MEDICARE: GAVIOTA DIALYSIS, LLC

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	:	1104217918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAVIOTA DIALYSIS, LLC

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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 DELTONA BLVD
Second Line	:	STE 26
City	:	DELTONA
State	:	FL
Zip	:	32725-6389
Country	:	US
Telephone Number	:	386-574-0225
Fax Number	:	386-574-6460

Authorized Official
Title or Position	:	VP, LICENSURE & CERTIFICATION
Name	:	SAMUEL WEY
Credential	:
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	02/16/2015
Last Update Date	:	02/03/2026

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Directions to “GAVIOTA DIALYSIS, LLC ” Practice Location

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