Provider Demographics
NPI:1013970110
Name:DVA RENAL HEALTHCARE INC
Entity Type:Organization
Organization Name:DVA RENAL HEALTHCARE INC
Other - Org Name:SOUTH HILL DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
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:253-733-4501
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:ATT: L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-238-3051
Mailing Address - Fax:800-246-8346
Practice Address - Street 1:525 ALEXANDRIA PIKE
Practice Address - Street 2:STE 120
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-3243
Practice Address - Country:US
Practice Address - Phone:859-442-5539
Practice Address - Fax:859-442-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300121261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2121457Medicaid
KY3900020300Medicaid
KY3900020300Medicaid