Provider Demographics
NPI:1821840992
Name:VINCENT, CALEB RAY
Entity type:Individual
Prefix:MR
First Name:CALEB
Middle Name:RAY
Last Name:VINCENT
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 1:1221 NORTH HEINCKE RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342
Mailing Address - Country:US
Mailing Address - Phone:513-263-0247
Mailing Address - Fax:
Practice Address - Street 1:10400 BLACKLICK EASTERN RD.
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-8235
Practice Address - Country:US
Practice Address - Phone:937-610-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2025-05-15
Deactivation Date:2025-04-18
Deactivation Code:
Reactivation Date:2025-05-15
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0487170Medicaid