Provider Demographics
NPI:1164008777
Name:EMD GROUP HOME, LLC
Entity Type:Organization
Organization Name:EMD GROUP HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARYSE
Authorized Official - Middle Name:
Authorized Official - Last Name:ISAMBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-295-1350
Mailing Address - Street 1:15113 HOLLEYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1050
Mailing Address - Country:US
Mailing Address - Phone:571-295-1350
Mailing Address - Fax:
Practice Address - Street 1:15113 HOLLEYSIDE DR
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:VA
Practice Address - Zip Code:22025-1050
Practice Address - Country:US
Practice Address - Phone:571-295-1350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health