Healthcare Provider Details

I. General information

NPI: 1255328662
Provider Name (Legal Business Name): 5040 PHILADELPHIA DRIVE OPERATING COMPANY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 PHILADELPHIA DR
DAYTON OH
45415-3604
US

IV. Provider business mailing address

5040 PHILADELPHIA DR
DAYTON OH
45415-3604
US

V. Phone/Fax

Practice location:
  • Phone: 937-278-0404
  • Fax: 937-278-0092
Mailing address:
  • Phone: 937-278-0404
  • Fax: 937-278-0092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1923N
License Number StateOH

VIII. Authorized Official

Name: JOSH HUFF
Title or Position: ADMINISTRATOR
Credential:
Phone: 937-278-0404