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General NPI Number Information
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NPI Number | 1699178723
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Entity Type | Organization
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Legal Business Name | INDEPENDENT PROVIDER
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Dates
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Enumeration Date | 10/03/2014
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Last Update Date | 10/03/2014
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Provider Practice Location Address
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Address Line | 5659 TROY VILLA BLVD
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City | DAYTON
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State | OH
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Zip | 45424-2645
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Country | US
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Telephone | 979-451-3843
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Fax |
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Provider Business Mailing Address
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Address Line | 5659 TROY VILLA BLVD
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City | DAYTON
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State | OH
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Zip | 45424-2645
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Country | US
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Telephone | 979-451-3843
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Fax |
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Authorized Official
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Title or Position | INDEPENDENT PROVIDER
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Name | LA'TASHA DENISE LEE
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Credential |
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Telephone | 979-451-3843
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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