1982667408 NPI number — DCA OF CENTRAL VALDOSTA LLC

Table of content: (NPI 1982667408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982667408 NPI number — DCA OF CENTRAL VALDOSTA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DCA OF CENTRAL VALDOSTA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
U S RENAL CARE CENTRAL VALDOSTA DIALYSIS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982667408
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19119
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72403-6601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-931-5400
Provider Business Mailing Address Fax Number:
870-931-5418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 N PATTERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31601-4608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-219-0099
Provider Business Practice Location Address Fax Number:
229-219-7331
Provider Enumeration Date:
04/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEINBERG
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT & SECRETARY
Authorized Official Telephone Number:
214-736-2700

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000895309E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112699 . This is a "VA MEDICAL CENTER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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