1689782302 NPI number — VETERANS ADMINISTRATION MEDICAL CENTER

Table of content: EDMIRE FLORE SOUFFRANT MD (NPI 1386056430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689782302 NPI number — VETERANS ADMINISTRATION MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VETERANS ADMINISTRATION MEDICAL CENTER
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:
1689782302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6720 AFTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45415-1436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-454-5026
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 W 3RD ST
Provider Second Line Business Practice Location Address:
#117A-SPEECH CLINIC
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45428-9000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-262-2148
Provider Business Practice Location Address Fax Number:
937-267-5322
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VAN WINKLE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
REHAB CARELINE MANAGER
Authorized Official Telephone Number:
937-268-6511

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  SP2055 , 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)





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