Basic Information
Provider Information | |||||||||
NPI: | 1265409213 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DVA HEALTHCARE RENAL CARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GREATER DAYTONA HOME TRAINING DIALYSIS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5200 VIRGINIA WAY | ||||||||
Address2: | STE 400 | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370277569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153204218 | ||||||||
FaxNumber: | 3032097825 | ||||||||
Practice Location | |||||||||
Address1: | 575 N CLYDE MORRIS BLVD | ||||||||
Address2: | STE A | ||||||||
City: | DAYTONA BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 321142323 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3862587719 | ||||||||
FaxNumber: | 3862587524 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2006 | ||||||||
LastUpdateDate: | 07/20/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HILGER | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2533821919 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 200518221 | 05 | FL |   | MEDICAID |