Provider Demographics
NPI:1740210863
Name:CG-DSA, LLC
Entity Type:Organization
Organization Name:CG-DSA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-299-5161
Mailing Address - Street 1:4800 OVERTON PLAZA
Mailing Address - Street 2:SUITE 440
Mailing Address - City:FORTH WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4435
Mailing Address - Country:US
Mailing Address - Phone:800-299-5161
Mailing Address - Fax:
Practice Address - Street 1:740 OAK BLVD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1459
Practice Address - Country:US
Practice Address - Phone:765-649-4247
Practice Address - Fax:765-642-8512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100243450CMedicaid