Healthcare Provider Details

I. General information

NPI: 1710713045
Provider Name (Legal Business Name): ST LEONARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 CLYO RD
DAYTON OH
45458-2720
US

IV. Provider business mailing address

8100 CLYO RD
DAYTON OH
45458-2720
US

V. Phone/Fax

Practice location:
  • Phone: 937-433-0480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: MATTHEW WINE
Title or Position: DIRECTOR OF ANCILLARY CONTRACTING
Credential:
Phone: 513-562-7202