Provider Demographics
NPI: | 1235587817 |
---|---|
Name: | 8759 CONTEE ROAD APT 404 LAUREL MD 20708 |
Entity Type: | Organization |
Organization Name: | 8759 CONTEE ROAD APT 404 LAUREL MD 20708 |
Other - Org Name: | 7009 WOODSTREAM TER LANHAM MD 20706 |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | HHA |
Authorized Official - Prefix: | MISS |
Authorized Official - First Name: | MARIE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LUM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | HHA |
Authorized Official - Phone: | 240-667-6347 |
Mailing Address - Street 1: | 8759 CONTEE RD APT 404 |
Mailing Address - Street 2: | |
Mailing Address - City: | LAUREL |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 20708-1927 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 240-667-6347 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 8759 CONTEE RD APT 404 |
Practice Address - Street 2: | |
Practice Address - City: | LAUREL |
Practice Address - State: | MD |
Practice Address - Zip Code: | 20708-1927 |
Practice Address - Country: | US |
Practice Address - Phone: | 240-667-6347 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-05-24 |
Last Update Date: | 2016-05-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
DC | HHA12114 | 251E00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251E00000X | Agencies | Home Health |