Healthcare Provider Details

I. General information

NPI: 1588694616
Provider Name (Legal Business Name): CG-DSA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 GASLITE LANE
GREENFIELD IN
46140-1012
US

IV. Provider business mailing address

4800 OVERTON PLAZA SUITE 440
FORT WORTH TX
76109-4435
US

V. Phone/Fax

Practice location:
  • Phone: 765-649-4247
  • Fax: 765-642-8512
Mailing address:
  • Phone: 800-299-5161
  • Fax: 317-462-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ANNA TODD
Title or Position: OPERATIONS BUSINESS MANAGER
Credential:
Phone: 800-299-5161