Provider Demographics
NPI:1710066428
Name:DAVITA TIDEWATER - VIRGINIA BEACH, LLC
Entity Type:Organization
Organization Name:DAVITA TIDEWATER - VIRGINIA BEACH, LLC
Other - Org Name:CAMELOT DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:USILTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-541-7922
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:STE 400 L&C
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4218
Mailing Address - Fax:303-209-7825
Practice Address - Street 1:1800 CAMELOT DR
Practice Address - Street 2:STE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2440
Practice Address - Country:US
Practice Address - Phone:757-481-6879
Practice Address - Fax:757-496-0187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment