Provider Demographics
NPI:1326012311
Name:DVA HEALTHCARE RENAL CARE INC
Entity Type:Organization
Organization Name:DVA HEALTHCARE RENAL CARE INC
Other - Org Name:FONTANA DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:HILGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-733-4500
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT 4TH FL
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6765
Mailing Address - Fax:833-782-9089
Practice Address - Street 1:17590 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3785
Practice Address - Country:US
Practice Address - Phone:909-356-9664
Practice Address - Fax:909-356-9687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000334261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1326012311Medicaid
052682Medicare Oscar/Certification