Provider Demographics
NPI:1255360384
Name:DVA RENAL HEALTHCARE INC
Entity type:Organization
Organization Name:DVA RENAL HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR LICENSURE&CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
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:615-341-6410
Mailing Address - Fax:888-662-8259
Practice Address - Street 1:1030 KINGS HWY N
Practice Address - Street 2:STE 100
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1907
Practice Address - Country:US
Practice Address - Phone:856-321-0111
Practice Address - Fax:856-482-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40401261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01831220Medicaid
NJ5636400Medicaid
DE001093234Medicaid