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	281P00000X	Chronic Disease Hospital	OTC-3619	AZ

General Provider Information

NPI Number	:	1164785747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DVA HEALTHCARE RENAL CARE, INC.

Provider Business Mailing Address
First Line	:	2130 W 24TH ST
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-6122
Country	:	US
Telephone Number	:	928-783-6122
Fax Number	:

Provider Business Practice Location Address
First Line	:	2130 W 24TH ST
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-6122
Country	:	US
Telephone Number	:	928-783-2365
Fax Number	:

Authorized Official
Title or Position	:	NO RESPONSE CLAIMS MANAGER
Name	:	TYLER BLOOM
Credential	:
Telephone Number	:	253-382-1108

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	06/19/2012

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