Basic Information
Provider Information | |||||||||
NPI: | 1871556381 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DCA OF ROYSTON LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | U S RENAL CARE ROYSTON DIALYSIS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 713158 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452713158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709315400 | ||||||||
FaxNumber: | 8709315418 | ||||||||
Practice Location | |||||||||
Address1: | 611 COOK ST | ||||||||
Address2: |   | ||||||||
City: | ROYSTON | ||||||||
State: | GA | ||||||||
PostalCode: | 306623933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062450817 | ||||||||
FaxNumber: | 7062456450 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2006 | ||||||||
LastUpdateDate: | 10/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEINBERG | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 2147362700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | U S RENAL CARE INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 000961914A | 05 | GA |   | MEDICAID |