MEDICARE: ST VINCENT DE PAUL SOCIAL SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1366125866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST VINCENT DE PAUL SOCIAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	120 W APPLE ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45402-2617
Country	:	US
Telephone Number	:	937-222-7349
Fax Number	:	937-461-7837

Provider Business Practice Location Address
First Line	:	1540 BROWNLEIGH RD
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45429-3928
Country	:	US
Telephone Number	:	937-630-3950
Fax Number	:	630-395-3937

Authorized Official
Title or Position	:	DIRECTOR OF HOUSING MISNITIRES
Name	:	MR. MICHAEL CHRISTOPOHER GOEBEL
Credential	:	LSW, LCDC III
Telephone Number	:	937-681-0943

Provider Enumeration Date	:	08/10/2023
Last Update Date	:	08/10/2023

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