Provider Demographics
NPI:1881668796
Name:DVA RENAL HEALTHCARE INC
Entity Type:Organization
Organization Name:DVA RENAL HEALTHCARE INC
Other - Org Name:GRASS VALLEY DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR 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:AO
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 1:360 CROWN POINT CIR
Practice Address - Street 2:STE 210
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-2543
Practice Address - Country:US
Practice Address - Phone:530-477-0734
Practice Address - Fax:530-477-0178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000483261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1881668796Medicaid
CA1881668796Medicaid