Healthcare Provider Details

I. General information

NPI: 1396578373
Provider Name (Legal Business Name): DANIEL TODD BOURNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 KETTERING BLVD STE 324
MORAINE OH
45439-1948
US

IV. Provider business mailing address

1111 DEERFIELD RD UNIT 409
LEBANON OH
45036-7115
US

V. Phone/Fax

Practice location:
  • Phone: 937-882-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: