Provider Demographics
NPI:1962476606
Name:DVA RENAL HEALTHCARE INC
Entity Type:Organization
Organization Name:DVA RENAL HEALTHCARE INC
Other - Org Name:SADDLEBACK DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR 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 1:23141 PLAZA POINTE DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1425
Practice Address - Country:US
Practice Address - Phone:949-588-9211
Practice Address - Fax:949-588-9299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000693261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962476606Medicaid
052808Medicare Oscar/Certification