MEDICARE: ENLIGHTENED THERAPY ASSOCIATES, 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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1871632182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENLIGHTENED THERAPY ASSOCIATES, INC.

Provider Business Mailing Address
First Line	:	77 E WOODBURY DR
Second Line	:	SUITE 106
City	:	DAYTON
State	:	OH
Zip	:	45415-2855
Country	:	US
Telephone Number	:	937-278-1779
Fax Number	:	937-278-4197

Provider Business Practice Location Address
First Line	:	2510 COMMONS BLVD
Second Line	:	SUITE 240
City	:	BEAVERCREEK
State	:	OH
Zip	:	45431-3809
Country	:	US
Telephone Number	:	937-429-8620
Fax Number	:	937-429-8629

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JUDITH ANN O'CONNELL
Credential	:	D.O.
Telephone Number	:	937-278-1779

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	08/22/2020

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