Provider Demographics
NPI:1497295406
Name:MYPOTENTIAL CLINIC - ROCKVILLE LLC
Entity Type:Organization
Organization Name:MYPOTENTIAL CLINIC - ROCKVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAZZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-354-2710
Mailing Address - Street 1:2301 RESEARCH BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3204
Mailing Address - Country:US
Mailing Address - Phone:301-354-2710
Mailing Address - Fax:
Practice Address - Street 1:9701 VEIRS DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3414
Practice Address - Country:US
Practice Address - Phone:301-424-9560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL LUTHERAN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-24
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center