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	091	LA

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	:	1750340816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DVA RENAL HEALTHCARE 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	:	615-320-4218
Fax Number	:	303-209-7825

Provider Business Practice Location Address
First Line	:	4015 COMMON ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70607-2942
Country	:	US
Telephone Number	:	337-562-2022
Fax Number	:	337-562-2555

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

Provider Enumeration Date	:	03/18/2006
Last Update Date	:	07/11/2007

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