Provider Demographics
NPI:1447226204
Name:DVA RENAL HEALTHCARE INC
Entity Type:Organization
Organization Name:DVA RENAL HEALTHCARE INC
Other - Org Name:SAN JUAN CAPISTRANO SOUTH 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:
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:615-238-3085
Mailing Address - Fax:800-268-9682
Practice Address - Street 1:31736 RANCHO VIEJO RD
Practice Address - Street 2:STE D
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2783
Practice Address - Country:US
Practice Address - Phone:949-240-1454
Practice Address - Fax:949-240-0735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000680261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1447226204Medicaid
052648Medicare Oscar/Certification