Provider Demographics
NPI:1275182560
Name:DERVAN HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:DERVAN HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:BLANCHE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOKOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-728-3783
Mailing Address - Street 1:11303 SPRINGPARK CT
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9611
Mailing Address - Country:US
Mailing Address - Phone:301-728-3783
Mailing Address - Fax:
Practice Address - Street 1:3849 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-1309
Practice Address - Country:US
Practice Address - Phone:301-728-3783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care