Healthcare Provider Details

I. General information

NPI: 1639472558
Provider Name (Legal Business Name): FOUR SEASONS OF DAYTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 COVENANT HOUSE DR
DAYTON OH
45426-2007
US

IV. Provider business mailing address

4911 COVENANT HOUSE DR
DAYTON OH
45426-2007
US

V. Phone/Fax

Practice location:
  • Phone: 937-837-2651
  • Fax: 937-837-5831
Mailing address:
  • Phone: 937-837-2651
  • Fax: 937-837-5831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY ALAN ROSS
Title or Position: PRESIDENT
Credential:
Phone: 937-584-2497