Provider Demographics
NPI:1558944041
Name:RODRICK KOM EBUA, FNU
Entity Type:Individual
Prefix:
First Name:FNU
Middle Name:
Last Name:RODRICK KOM EBUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 NEW HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6945
Mailing Address - Country:US
Mailing Address - Phone:301-728-8020
Mailing Address - Fax:
Practice Address - Street 1:7401 NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6945
Practice Address - Country:US
Practice Address - Phone:301-728-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide