MEDICARE: FOUR SEASONS OF DAYTON, 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1639472558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUR SEASONS OF DAYTON, LLC

Provider Business Mailing Address
First Line	:	4911 COVENANT HOUSE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45426-2007
Country	:	US
Telephone Number	:	937-837-2651
Fax Number	:	937-837-5831

Provider Business Practice Location Address
First Line	:	4911 COVENANT HOUSE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45426-2007
Country	:	US
Telephone Number	:	937-837-2651
Fax Number	:	937-837-5831

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TIMOTHY ALAN ROSS
Credential	:
Telephone Number	:	937-584-2497

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	12/15/2010

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Directions to “FOUR SEASONS OF DAYTON, LLC ” Practice Location

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