1396949400 NPI number — DAYTON ARTIFICIAL LIMB CLINIC, INC

Table of content: (NPI 1396949400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396949400 NPI number — DAYTON ARTIFICIAL LIMB CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAYTON ARTIFICIAL LIMB CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396949400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 HARCO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45315-8793
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-898-2200
Provider Business Mailing Address Fax Number:
937-832-5361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 HARCO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45315-8793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-898-2200
Provider Business Practice Location Address Fax Number:
936-832-5361
Provider Enumeration Date:
06/13/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SLEMKER
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
CLAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
937-898-2200

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  LP0114 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , with the licence number: CPO1502 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000020050 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 311468023-00 . This is a "BWC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2009589 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".