Provider Demographics
NPI:1295485589
Name:ADAMS, ANDRE AL
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:AL
Last Name:ADAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 FIVE OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-5219
Mailing Address - Country:US
Mailing Address - Phone:937-603-2833
Mailing Address - Fax:
Practice Address - Street 1:727 FIVE OAKS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-5219
Practice Address - Country:US
Practice Address - Phone:937-603-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSD762973172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver