Provider Demographics
NPI:1578729331
Name:ENVISIONCARE MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ENVISIONCARE MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CHINWE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NDUBISI
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, CRNP-F, ARNP-F
Authorized Official - Phone:301-237-7383
Mailing Address - Street 1:1400 MERCANTILE LN
Mailing Address - Street 2:SUITE 124
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5341
Mailing Address - Country:US
Mailing Address - Phone:301-322-9292
Mailing Address - Fax:301-322-9555
Practice Address - Street 1:10507 MONTANA TER
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-6034
Practice Address - Country:US
Practice Address - Phone:301-237-7383
Practice Address - Fax:301-322-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDNP117688261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1770745184OtherNPI-CMS