MEDICARE: CG-DSA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility

General Provider Information

NPI Number	:	1225611767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CG-DSA, LLC

Provider Business Mailing Address
First Line	:	4800 OVERTON PLZ STE 440
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4435
Country	:	US
Telephone Number	:	800-299-5161
Fax Number	:	817-447-3033

Provider Business Practice Location Address
First Line	:	7603 E 10TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-5101
Country	:	US
Telephone Number	:	317-477-0093
Fax Number	:

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

Provider Enumeration Date	:	05/03/2021
Last Update Date	:	05/03/2021

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