NPIMap

Organization Active NPI

Dva Renal Healthcare Inc

Doing business as Goldsboro South Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Goldsboro, NC
National Provider Identifier
1821058900
Registry record updated Jan 30, 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 RENAL HEALTHCARE INC
Doing business as
Goldsboro South Dialysis
Practice address
1704 Wayne Memorial Dr
Goldsboro, NC 27534-2240
Phone
(919) 739-6505
Fax
(919) 739-6506
NPI assigned
Mar 24, 2006
Last updated
Jan 30, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 30, 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

1704 Wayne Memorial Dr
Goldsboro, NC 27534-2240

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
3412587MedicaidNC

Other names 1

  • Goldsboro South Dialysis Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030508000050 NC Part A Provider - End-Stage Renal Disease Facility (ESRD) 0840107611 Practice locations: Goldsboro, NC

National Provider Directory

National Provider Directory
Tax ID family
Gambro Healthcare Hunti173 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 9

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

Locations

1704 Wayne Memorial Dr
Goldsboro, NC 27534
Phone (919) 739-6505

NPI Registry JSON

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

{
    "created_epoch": "1143158400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1706572800000",
    "number": "1821058900",
    "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",
            "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": "1704 WAYNE MEMORIAL DR",
            "city": "GOLDSBORO",
            "state": "NC",
            "postal_code": "275342240",
            "telephone_number": "919-739-6505",
            "fax_number": "919-739-6506"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DVA RENAL HEALTHCARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-24",
        "last_updated": "2024-01-30",
        "certification_date": "2024-01-30",
        "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": "3412587",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Goldsboro South Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Goldsboro South Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Goldsboro, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.