Healthcare Provider Details

I. General information

NPI: 1083724298
Provider Name (Legal Business Name): RCG OF MAYERSVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20019 HIGHWAY 61
ROLLING FORK MS
39159-5204
US

IV. Provider business mailing address

PO BOX 5757
GREENVILLE MS
38704-5757
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-2272
  • Fax: 662-378-2879
Mailing address:
  • Phone: 662-873-2272
  • Fax: 662-378-2879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NED KRONFOL
Title or Position: OWNER
Credential: MD
Phone: 662-335-4105