Basic Information
| Provider Information | |||||||||
| NPI: | 1477517738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DVA HEALTHCARE RENAL CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ARLINGTON DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L & C DEPARTMENT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204214 | ||||||||
| FaxNumber: | 8669443352 | ||||||||
| Practice Location | |||||||||
| Address1: | 4805 1ST ST N | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222032603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035270652 | ||||||||
| FaxNumber: | 7035270956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/25/2020 | ||||||||
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 | 054347200 | 05 | DC | MEDICAID | 1477517738 | 05 | VA | MEDICAID | 009700400 | 05 | MD | MEDICAID |