Healthcare Provider Details

I. General information

NPI: 1538643135
Provider Name (Legal Business Name): KENNETH ALAN BAILOR RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 MECHANICSBURG RD
SPRINGFIELD OH
45503-3147
US

IV. Provider business mailing address

1918 MECHANICSBURG RD
SPRINGFIELD OH
45503-3147
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-6101
  • Fax: 937-399-6609
Mailing address:
  • Phone: 937-399-6101
  • Fax: 937-339-6609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number27036
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: