Healthcare Provider Details

I. General information

NPI: 1497472211
Provider Name (Legal Business Name): BACK TO BASICS YOUTH EDUCATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W 2ND ST STE 611
DAYTON OH
45402-1657
US

IV. Provider business mailing address

1014 MERRYWOOD DR
ENGLEWOOD OH
45322-2445
US

V. Phone/Fax

Practice location:
  • Phone: 937-248-5360
  • Fax:
Mailing address:
  • Phone: 937-248-5360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: LAWRENCE LINDSEY
Title or Position: DIRECTOR
Credential:
Phone: 937-248-5360