Provider Demographics
NPI:1033179874
Name:DVA HEALTHCARE RENAL CARE INC
Entity Type:Organization
Organization Name:DVA HEALTHCARE RENAL CARE INC
Other - Org Name:LANDOVER DIALYSIS
Other - Org Type:Doing Business As
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 DEPARTMENT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4214
Mailing Address - Fax:866-944-3352
Practice Address - Street 1:1200 MERCANTILE LN
Practice Address - Street 2:STE 105
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5389
Practice Address - Country:US
Practice Address - Phone:301-322-2861
Practice Address - Fax:301-322-5829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDE2545261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD763011500Medicaid
VA1033179874Medicaid
DC033657400Medicaid
MD212545Medicare Oscar/Certification