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	ESRD001131	GA

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	:	1104895143
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	:	L & C DEPARTMENT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 SCRANTON CONNECTOR
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31525-1862
Country	:	US
Telephone Number	:	912-264-8657
Fax Number	:	912-265-6542

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	08/07/2025

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