NPIMap

Organization Active NPI

Dva Healthcare Renal Care, Inc.

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Lake Wales, FL
National Provider Identifier
1750358172
Registry record updated Mar 17, 2026
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
Lake Wales Dialysis Center
Practice address
1125 Bryn Mawr Ave
Lake Wales, FL 33853-4333
Phone
(863) 679-9851
Fax
(863) 679-9856
NPI assigned
Mar 3, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 17, 2026

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

Authorized official

Name
Samuel 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

1125 Bryn Mawr Ave
Lake Wales, FL 33853-4333

Mailing address

5200 Virginia Way
L&C Dept
Brentwood, TN 37027-7569

Other identifiers 1

IdentifierTypeStateIssuer
200518217MedicaidFL

Other names 1

  • Lake Wales Dialysis Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030516000008 FL Part A Provider - End-Stage Renal Disease Facility (ESRD) 7517875545 Practice locations: Lake Wales, FL

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Lake Wales DialysisCCN 102712
Overall star rating
1.0 of 5
Ownership
Profit
Certified
Dec 2, 1996
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
12

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
10D0919341Lake Wales Dialysis Center1125 Bryn Mawr Ave, Lake Wales, FL 33853Certificate of waiverSep 4, 2026

National Provider Directory

National Provider Directory
Tax ID family
CDS of Zephyrhills194 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 16

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

View all 16

Member of 1

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

Networks

  • Freedom Health HMO NetworkPlans: Freedom Platinum Rewards Plan Rx (HMO) (H5427-102-000, H5427); Freedom VIP Care (HMO C-SNP) (H5427-070-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-108-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-099-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-107-000, H5427); Freedom Maximo (HMO-POS) (H5427-113-000, H5427); Freedom Savings Plan (HMO) (H5427-052-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-096-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-105-000, H5427); Freedom Medi-Medi Full (HMO D-SNP) (H5427-087-000, H5427)…
  • Optimum HealthCare HMO NetworkPlans: Optimum Diamond Rewards (HMO C-SNP) (H5594-028-000, H5594); Optimum Diamond (HMO C-SNP) (H5594-036-000, H5594); Optimum Diamond Rewards (HMO C-SNP) (H5594-034-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-029-000, H5594); Optimum Platinum Plan (HMO) (H5594-002-000, H5594); Optimum Gold Plus Plan (HMO) (H5594-032-000, H5594); Optimum Diamond Savings COPD (HMO C-SNP) (H5594-031-000, H5594); Optimum Diamond Savings (HMO C-SNP) (H5594-030-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-035-000, H5594)

Practitioners & affiliated clinicians

Affiliated clinicians 1

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": "1141344000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1773705600000",
    "number": "1750358172",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "L&C DEPT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370277569"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1125 BRYN MAWR AVE",
            "city": "LAKE WALES",
            "state": "FL",
            "postal_code": "338534333",
            "telephone_number": "863-679-9851",
            "fax_number": "863-679-9856"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DVA HEALTHCARE RENAL CARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-03",
        "last_updated": "2026-03-17",
        "certification_date": "2026-03-17",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "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": "200518217",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Wales Dialysis Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Wales, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2026; 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.