Provider Demographics
NPI:1124206594
Name:88 MDOS
Entity Type:Organization
Organization Name:88 MDOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:WELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-257-1363
Mailing Address - Street 1:7012 WINTER HILL CT
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459
Mailing Address - Country:US
Mailing Address - Phone:954-647-7442
Mailing Address - Fax:
Practice Address - Street 1:88 SUGAR MAPLE DR.
Practice Address - Street 2:
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-257-1363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No282N00000XHospitalsGeneral Acute Care Hospital
No283Q00000XHospitalsPsychiatric Hospital
No286500000XHospitalsMilitary Hospital