Provider Demographics
NPI:1417037268
Name:DAYTON VETERANS AFFAIRS MEDICAL CENTER
Entity Type:Organization
Organization Name:DAYTON VETERANS AFFAIRS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VOCATIONAL REHABILITATION SPECIALIS
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCINI
Authorized Official - Suffix:JR
Authorized Official - Credentials:CRC
Authorized Official - Phone:937-268-6511
Mailing Address - Street 1:3547 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2501
Mailing Address - Country:US
Mailing Address - Phone:937-293-7484
Mailing Address - Fax:
Practice Address - Street 1:3547 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2501
Practice Address - Country:US
Practice Address - Phone:937-293-7484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-0016717276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00016730OtherCERTIFICATION