1013980747 NPI number — DVA HEALTHCARE RENAL CARE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013980747 NPI number — DVA HEALTHCARE RENAL CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DVA HEALTHCARE RENAL CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OZARK DIALYSIS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013980747
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 VIRGINIA WAY
Provider Second Line Business Mailing Address:
L&C DEPT
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-7569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-320-4268
Provider Business Mailing Address Fax Number:
877-238-0567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 BUNTING DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OZARK
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36360-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-774-1410
Provider Business Practice Location Address Fax Number:
334-774-2690
Provider Enumeration Date:
02/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEY
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
T
Authorized Official Title or Position:
SR DIR LICENSURE & CERTIFICATION
Authorized Official Telephone Number:
615-341-6641

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  S2301 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 890060400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DIA2544D , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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