Basic Information
| Provider Information | |||||||||
| NPI: | 1447212451 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DVA HEALTHCARE RENAL CARE INC | ||||||||
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| OtherOrganizationName: | ST MATTHEWS DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | STE. 400 L&C | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204218 | ||||||||
| FaxNumber: | 3032097825 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 N F R HUFF DR | ||||||||
| Address2: | |||||||||
| City: | ST MATTHEWS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291359596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036557758 | ||||||||
| FaxNumber: | 8036557764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | USILTON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7705417922 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | ERD066 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 425623 | 05 | SC | MEDICAID |