Provider Demographics
NPI:1114674058
Name:ALTA HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:ALTA HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DIBONGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-506-1728
Mailing Address - Street 1:21506 MANOR VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-5924
Mailing Address - Country:US
Mailing Address - Phone:240-506-1728
Mailing Address - Fax:
Practice Address - Street 1:101 LAKEFOREST BLVD STE 250
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2633
Practice Address - Country:US
Practice Address - Phone:240-801-9818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder