Provider Demographics
NPI:1679129472
Name:SOUTH COMMUNITY
Entity Type:Organization
Organization Name:SOUTH COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STUDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALENCIA
Authorized Official - Middle Name:LANIER
Authorized Official - Last Name:TERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:INTERN
Authorized Official - Phone:937-293-8300
Mailing Address - Street 1:1339 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-4220
Mailing Address - Country:US
Mailing Address - Phone:937-276-2899
Mailing Address - Fax:
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1983
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:937-534-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management