Healthcare Provider Details

I. General information

NPI: 1114919065
Provider Name (Legal Business Name): DVL VASCULAR LAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 S EDWIN C MOSES BLVD SUITE 3H
DAYTON OH
45417-3461
US

IV. Provider business mailing address

PO BOX 276
ENGLEWOOD OH
45322-0276
US

V. Phone/Fax

Practice location:
  • Phone: 937-220-9934
  • Fax: 937-220-9936
Mailing address:
  • Phone: 937-220-9934
  • Fax: 937-220-9936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number804704
License Number StateOH

VIII. Authorized Official

Name: MRS. SHARON KAYE ROBERTS
Title or Position: PRESIDENT
Credential: RVT
Phone: 937-220-9934