Basic Information
| Provider Information | |||||||||
| NPI: | 1508828765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DVA RENAL HEALTHCARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOUNTAIN VIEW DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204435 | ||||||||
| FaxNumber: | 3032097821 | ||||||||
| Practice Location | |||||||||
| Address1: | 2881 BUSINESS PARK CT | ||||||||
| Address2: | STE 130 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891289019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023419551 | ||||||||
| FaxNumber: | 7023419379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 02/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | HILGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 2201ESR12 | NV | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 552449 | 05 | AZ | MEDICAID | XCDC00691 | 05 | CA | MEDICAID | 004502010 | 05 | NV | MEDICAID | 82537800 | 05 | WI | MEDICAID |