Healthcare Provider Details

I. General information

NPI: 1093324881
Provider Name (Legal Business Name): TISCHA ELAINE COATES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4661 MERRICK DR
DAYTON OH
45415-3354
US

IV. Provider business mailing address

4661 MERRICK DR
DAYTON OH
45415-3354
US

V. Phone/Fax

Practice location:
  • Phone: 937-245-2642
  • Fax: 937-278-9418
Mailing address:
  • Phone: 937-245-2642
  • Fax: 937-278-9418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateOH
# 6
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: