Provider Demographics
NPI:1164785747
Name:DVA HEALTHCARE RENAL CARE, INC.
Entity Type:Organization
Organization Name:DVA HEALTHCARE RENAL CARE, INC.
Other - Org Name:YUMA DIALYSIS
Other - Org Type:Other Name
Authorized Official - Title/Position:NO RESPONSE CLAIMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-382-1108
Mailing Address - Street 1:2130 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6122
Mailing Address - Country:US
Mailing Address - Phone:928-783-6122
Mailing Address - Fax:
Practice Address - Street 1:2130 W 24TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6122
Practice Address - Country:US
Practice Address - Phone:928-783-2365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC-3619281P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281P00000XHospitalsChronic Disease Hospital