Basic Information
| Provider Information | |||||||||
| NPI: | 1679129472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH COMMUNITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1339 KINGSLEY AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454064220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372762899 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
| FaxNumber: | 9375341350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2019 | ||||||||
| LastUpdateDate: | 08/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | TERRELL | ||||||||
| AuthorizedOfficialFirstName: | VALENCIA | ||||||||
| AuthorizedOfficialMiddleName: | LANIER | ||||||||
| AuthorizedOfficialTitleorPosition: | STUDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372938300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | INTERN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.