Provider Demographics
NPI:1346200334
Name:DVA HEALTHCARE RENAL CARE, INC.
Entity Type:Organization
Organization Name:DVA HEALTHCARE RENAL CARE, INC.
Other - Org Name:HARBOR PARK 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 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 1:111 CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1392
Practice Address - Country:US
Practice Address - Phone:410-354-3037
Practice Address - Fax:410-354-3095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDE2556261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD791600100Medicaid
PA1007635580125Medicaid
PA1007635580125Medicaid