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General NPI Number Information
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NPI Number | 1538192224
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Entity Type | Organization
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Legal Business Name | ST. ELIZABETH'S DIAGNOSTIC
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 06/17/2013
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Provider Practice Location Address
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Address Line | 1 ELIZABETH PL 2ND FLOOR
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City | DAYTON
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State | OH
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Zip | 45417-3445
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Country | US
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Telephone | 937-222-5390
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Fax | 937-222-5331
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Provider Business Mailing Address
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Address Line | 1 ELIZABETH PL
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City | DAYTON
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State | OH
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Zip | 45417-3445
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Country | US
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Telephone | 937-222-5390
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Fax | 937-222-5331
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Authorized Official
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Title or Position | CEO
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Name | MR. ETHAN FALLANG
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Credential |
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Telephone | 937-222-5390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 36D1033316
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License Number State | OH
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