Healthcare Provider Details

I. General information

NPI: 1164892949
Provider Name (Legal Business Name): DFAS-JFLL/IN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
DAYTON OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
DAYTON OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9926
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number01073515A
License Number StateIN

VIII. Authorized Official

Name: DR. ISAAC HUMPHREY
Title or Position: SUPERVISOR
Credential: MD
Phone: 937-257-9926