Healthcare Provider Details

I. General information

NPI: 1023119401
Provider Name (Legal Business Name): MR. HAROLD JACKSON DELOTELLE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W 3RD ST
DAYTON OH
45428-9000
US

IV. Provider business mailing address

2191 BASSETT CT
BEAVERCREEK OH
45434-7089
US

V. Phone/Fax

Practice location:
  • Phone: 937-268-6511
  • Fax:
Mailing address:
  • Phone: 937-427-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: