Basic Information
Provider Information | |||||||||
NPI: | 1407819089 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DVA RENAL HEALTHCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAWRENCEBURG DIALYSIS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5200 VIRGINIA WAY | ||||||||
Address2: | STE. 400 L&C | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370277569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153416657 | ||||||||
FaxNumber: | 8666519495 | ||||||||
Practice Location | |||||||||
Address1: | 2022 N LOCUST AVE | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 384642336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9317623136 | ||||||||
FaxNumber: | 9317626641 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 12/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HILGER | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9317623136 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 112 | TN | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 0442612 | 05 | TN |   | MEDICAID |