Healthcare Provider Details

I. General information

NPI: 1346262813
Provider Name (Legal Business Name): DAYTON VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 SO. A
RICHMOND IN
47374-6052
US

IV. Provider business mailing address

3205 CART RD
RICHMOND IN
47374-9345
US

V. Phone/Fax

Practice location:
  • Phone: 765-973-6915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number39000717A
License Number StateIN

VIII. Authorized Official

Name: MR. RAY HUGGER
Title or Position: OUTREACH COORDINATOR
Credential:
Phone: 765-973-6915