Provider Demographics
NPI:1124383146
Name:DANSFORTH, INC
Entity Type:Organization
Organization Name:DANSFORTH, INC
Other - Org Name:MEDCARE GENERAL, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-856-8736
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-0056
Mailing Address - Country:US
Mailing Address - Phone:770-856-8736
Mailing Address - Fax:
Practice Address - Street 1:245 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE100
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-9126
Practice Address - Country:US
Practice Address - Phone:770-856-8736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047279261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH00060Medicare UPIN