Provider Demographics
NPI:1467876458
Name:CHARISS FAMILY MEDICAL CLINIC AND MED SPA INC.
Entity Type:Organization
Organization Name:CHARISS FAMILY MEDICAL CLINIC AND MED SPA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIANA
Authorized Official - Middle Name:CHINYERE
Authorized Official - Last Name:KEKE-EKEKWE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:240-770-4315
Mailing Address - Street 1:9470 ANNAPOLIS RD STE 401
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3025
Mailing Address - Country:US
Mailing Address - Phone:240-770-4315
Mailing Address - Fax:240-770-4417
Practice Address - Street 1:9470 ANNAPOLIS ROAD SUITE 401
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706
Practice Address - Country:US
Practice Address - Phone:240-770-4315
Practice Address - Fax:240-770-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-11
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR124903172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD448130500Medicaid