Provider Demographics
NPI:1396949400
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:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:SLEMKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
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:937-898-2200
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:937-898-2200
Practice Address - Fax:936-832-5361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLP0114335E00000X
OHCPO1502335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000020050OtherANTHEM
OH311468023-00OtherBWC
OH2009589Medicaid