Healthcare Provider Details

I. General information

NPI: 1285110205
Provider Name (Legal Business Name): KEVIN ANTHONY CALLENDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 KETTERING BLVD
MORAINE OH
45439-1983
US

IV. Provider business mailing address

1001 AMBRIDGE RD
DAYTON OH
45459-4900
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-8300
  • Fax:
Mailing address:
  • Phone: 347-228-5285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1904096
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: