=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235285628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAYTON EYE SURGERY CENTER L L C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 81 SYLVANIA DR
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45440-3237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-431-9531
-----------------------------------------------------
Fax | 937-431-9532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81 SYLVANIA DR
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45440-3237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-431-9531
-----------------------------------------------------
Fax | 937-431-9532
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DON/ADMINISTRATOR
-----------------------------------------------------
Name | ANDREA WEISENBURGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-431-9531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 0553AS
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------