NPIMap

Organization Active NPI

Dva Healthcare Renal Care Inc

Doing business as South Charlotte Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Charlotte, NC
National Provider Identifier
1720047301
Registry record updated Jan 23, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
DVA HEALTHCARE RENAL CARE INC
Doing business as
South Charlotte Dialysis
Practice address
10504 Park Rd
Charlotte, NC 28210-8405
Phone
(980) 399-4784
Fax
(980) 399-4817
NPI assigned
Mar 21, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 23, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Samuel T Wey
Title
VP Licensure & Certification
Phone
(615) 341-6641

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X Primary

Addresses

Primary practice location

10504 Park Rd
Charlotte, NC 28210-8405

Mailing address

5200 Virginia Way
Att: L&C Dept
Brentwood, TN 37027-7569
Phone (615) 320-4593

Other identifiers 2

IdentifierTypeStateIssuer
NDC002MedicaidSC
3412523MedicaidNC

Other names 1

  • South Charlotte Dialysis Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030527000016 NC Part A Provider - End-Stage Renal Disease Facility (ESRD) 7517875545 Practice locations: Charlotte, NC

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita South Charlotte DialysisCCN 342523
Overall star rating
5.0 of 5
Ownership
Profit
Certified
Aug 4, 1986
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
23

Name & address match This facility record has no NPI; it was connected to this NPI by matching name and address.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D0655324South Charlotte Dialysis10504 Park Road, Charlotte, NC 28210Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Columbia Central194 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 15

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 15

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Practitioners & affiliated clinicians

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1142899200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705968000000",
    "number": "1720047301",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "ATT: L&C DEPT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370277569",
            "telephone_number": "615-320-4593",
            "fax_number": "800-293-5872"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10504 PARK RD",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282108405",
            "telephone_number": "980-399-4784",
            "fax_number": "980-399-4817"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DVA HEALTHCARE RENAL CARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-21",
        "last_updated": "2024-01-23",
        "certification_date": "2024-01-22",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "VP LICENSURE & CERTIFICATION",
        "authorized_official_telephone_number": "615-341-6641"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "NDC002",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3412523",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South Charlotte Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "South Charlotte Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Charlotte, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 23, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.