MEDICARE: DCA OF KENWOOD 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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770713026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DCA OF KENWOOD LLC

Provider Business Mailing Address
First Line	:	PO BOX 19119
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72403-6601
Country	:	US
Telephone Number	:	870-931-5400
Fax Number	:	870-931-5418

Provider Business Practice Location Address
First Line	:	5150 E GALBRAITH RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45236-2871
Country	:	US
Telephone Number	:	513-791-2698
Fax Number	:	513-791-6289

Authorized Official
Title or Position	:	VICE PRESIDENT & SECRETARY
Name	:	MR. THOMAS L. WEINBERG
Credential	:
Telephone Number	:	214-736-2700

Provider Enumeration Date	:	07/21/2009
Last Update Date	:	10/25/2013

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Directions to “DCA OF KENWOOD LLC ” Practice Location

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