Healthcare Provider Details

I. General information

NPI: 1699178723
Provider Name (Legal Business Name): INDEPENDENT PROVIDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5659 TROY VILLA BLVD
DAYTON OH
45424-2645
US

IV. Provider business mailing address

5659 TROY VILLA BLVD
DAYTON OH
45424-2645
US

V. Phone/Fax

Practice location:
  • Phone: 979-451-3843
  • Fax:
Mailing address:
  • Phone: 979-451-3843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: LA'TASHA DENISE LEE
Title or Position: INDEPENDENT PROVIDER
Credential:
Phone: 979-451-3843