Healthcare Provider Details

I. General information

NPI: 1245928894
Provider Name (Legal Business Name): GAP COMMUNITY COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 WARREN ST STE 178
DAYTON OH
45402-2808
US

IV. Provider business mailing address

436 WARREN ST STE 178
DAYTON OH
45402-2808
US

V. Phone/Fax

Practice location:
  • Phone: 937-271-1089
  • Fax:
Mailing address:
  • Phone: 937-271-1089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KYNA JOHNSON
Title or Position: CEO
Credential:
Phone: 937-271-1089