1962438671 NPI number — CG-DSA, LLC

Table of content: (NPI 1962438671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962438671 NPI number — CG-DSA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CG-DSA, 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:
Provider Other Organization Name Type Code:
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:
1962438671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4800 OVERTON PLAZA
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76109-4435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-299-5161
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2326 BERWICK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46176-3125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-477-0093
Provider Business Practice Location Address Fax Number:
317-348-3430
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TODD
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS BUSINESS MANAGER
Authorized Official Telephone Number:
800-299-5161

Provider Taxonomy Codes

  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100234640C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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