1851350714 NPI number — DVA HEALTHCARE OF MASSACHUSETTS INC

Table of content: (NPI 1851350714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851350714 NPI number — DVA HEALTHCARE OF MASSACHUSETTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DVA HEALTHCARE OF MASSACHUSETTS 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:
WELLESLEY 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:
1851350714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2007
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:
STE 400 L&C
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:
615-320-4218
Provider Business Mailing Address Fax Number:
303-209-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 WORCESTER ST
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
WELLESLEY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02481-5568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-431-1414
Provider Business Practice Location Address Fax Number:
781-431-1144
Provider Enumeration Date:
03/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
USILTON
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
O
Authorized Official Title or Position:
GROUP VICE PRESIDENT
Authorized Official Telephone Number:
770-541-7922

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  E5UZ , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1311387 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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