Provider Demographics
NPI:1902918790
Name:RCG OF LAKE VILLAGE, LLC
Entity Type:Organization
Organization Name:RCG OF LAKE VILLAGE, LLC
Other - Org Name:RCG LAKE VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NED
Authorized Official - Middle Name:O
Authorized Official - Last Name:KRONFOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-335-4105
Mailing Address - Street 1:505 ST. MARY STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-1722
Mailing Address - Country:US
Mailing Address - Phone:870-265-3837
Mailing Address - Fax:870-265-5061
Practice Address - Street 1:505 ST. MARY STREET
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-1722
Practice Address - Country:US
Practice Address - Phone:870-265-3837
Practice Address - Fax:870-265-5061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-04-24
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
042527Medicare ID - Type Unspecified