1649232703 NPI number — DVA RENAL HEALTHCARE INC

Table of content: (NPI 1649232703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649232703 NPI number — DVA RENAL HEALTHCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DVA RENAL HEALTHCARE 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:
Provider Other Organization Name Type Code:
6
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:
1649232703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2007
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:
10 GATEWAY CORNERS PARK
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29203-8905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-865-0554
Provider Business Practice Location Address Fax Number:
803-865-2816
Provider Enumeration Date:
04/04/2006

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:  ERD124 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ERD124 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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