Provider Demographics
NPI:1003545765
Name:COLEMAN MANAGEMENT GROUP VANDALIA, LLC
Entity Type:Organization
Organization Name:COLEMAN MANAGEMENT GROUP VANDALIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARLY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-264-1600
Mailing Address - Street 1:8605 N DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2403
Mailing Address - Country:US
Mailing Address - Phone:937-264-1600
Mailing Address - Fax:
Practice Address - Street 1:8605 N DIXIE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2403
Practice Address - Country:US
Practice Address - Phone:937-264-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLEMAN MANAGEMENT GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821210998OtherLEE R HENDRICKS
1457769846OtherCAITLIN LOCHTEFELD
1063903961OtherRACHEL EIFERT