Provider Demographics
NPI:1790748101
Name:DCA OF SO GA LLC
Entity Type:Organization
Organization Name:DCA OF SO GA LLC
Other - Org Name:U S RENAL CARE SOUTH GEORGIA DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT & SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-736-2700
Mailing Address - Street 1:PO BOX 19119
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-6601
Mailing Address - Country:US
Mailing Address - Phone:870-931-5400
Mailing Address - Fax:870-931-5418
Practice Address - Street 1:3564 N CROSSING CIR STE A
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6413
Practice Address - Country:US
Practice Address - Phone:229-249-3222
Practice Address - Fax:229-249-0775
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:U S RENAL CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-07
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000895309CMedicaid
GA000895309CMedicaid