Provider Demographics
NPI:1255308722
Name:DVA HEALTHCARE RENAL CARE INC
Entity Type:Organization
Organization Name:DVA HEALTHCARE RENAL CARE INC
Other - Org Name:FORT MYERS 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:AO
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:615-320-4593
Mailing Address - Fax:800-293-5872
Practice Address - Street 1:4220 EXECUTIVE CIR
Practice Address - Street 2:STE 38
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-8055
Practice Address - Country:US
Practice Address - Phone:239-274-3681
Practice Address - Fax:239-274-6168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL200518206Medicaid
102513Medicare Oscar/Certification