Healthcare Provider Details

I. General information

NPI: 1124206594
Provider Name (Legal Business Name): 88TH MEDGRP-WRIGHT-PATTERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 SUGAR MAPLE DR.
WPAFB OH
45433
US

IV. Provider business mailing address

7012 WINTER HILL CT
DAYTON OH
45459
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-1363
  • Fax:
Mailing address:
  • Phone: 954-647-7442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDON WELTON
Title or Position: PROGRAM DIRECTOR
Credential: M.D.
Phone: 937-257-1363