Provider Demographics
NPI:1720089253
Name:DAYTON ARTIFICIAL LIMB CLINIC, INC.
Entity Type:Organization
Organization Name:DAYTON ARTIFICIAL LIMB CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V P OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:LUCI
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:CP LP
Authorized Official - Phone:937-898-2200
Mailing Address - Street 1:700 HARCO DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45315-8793
Mailing Address - Country:US
Mailing Address - Phone:937-898-2000
Mailing Address - Fax:937-832-5361
Practice Address - Street 1:700 HARCO DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:OH
Practice Address - Zip Code:45315-8793
Practice Address - Country:US
Practice Address - Phone:937-898-2000
Practice Address - Fax:937-832-5361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCPO1502335E00000X
OHLPO114335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2009589Medicaid
OH000000020050OtherANTHEM
OH2009589Medicaid
OH2009589Medicaid