Provider Demographics
NPI:1073581203
Name:DVA HEALTHCARE RENAL CARE INC
Entity type:Organization
Organization Name:DVA HEALTHCARE RENAL CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, LICENSURE & CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2685 METROPOLITAN PKWY SW
Practice Address - Street 2:STE F
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7926
Practice Address - Country:US
Practice Address - Phone:404-761-2630
Practice Address - Fax:404-761-2618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001023261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000440074AMedicaid
DC035641900Medicaid
112568Medicare Oscar/Certification