Provider Demographics
NPI:1326001959
Name:DVA HEALTHCARE RENAL CARE INC
Entity Type:Organization
Organization Name:DVA HEALTHCARE RENAL CARE INC
Other - Org Name:DYERSBURG DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WINSTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-733-4501
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:615-320-4514
Mailing Address - Fax:866-594-9961
Practice Address - Street 1:1575 PARR AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3151
Practice Address - Country:US
Practice Address - Phone:731-286-5184
Practice Address - Fax:731-286-0174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202308359Medicaid
MO505217604Medicaid
MS00220633Medicaid
KY3900010400Medicaid
TN0442533Medicaid
442533Medicare Oscar/Certification