Healthcare Provider Details

I. General information

NPI: 1477261683
Provider Name (Legal Business Name): SIDEWALK SOLDIERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 XENIA AVE
DAYTON OH
45410-1824
US

IV. Provider business mailing address

526 XENIA AVE
DAYTON OH
45410-1824
US

V. Phone/Fax

Practice location:
  • Phone: 937-949-1524
  • Fax: 937-791-6613
Mailing address:
  • Phone: 513-371-9292
  • Fax: 937-791-6613

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

VIII. Authorized Official

Name: AMY CORNELIUS
Title or Position: CEO
Credential:
Phone: 585-336-7600