Provider Demographics
NPI:1619122504
Name:PREVENTION &MANAGEMENT OUTREACH CLINIC INC.
Entity Type:Organization
Organization Name:PREVENTION &MANAGEMENT OUTREACH CLINIC INC.
Other - Org Name:PREVENTION & MANAGEMENT OUTREACH CLINIC INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-312-3126
Mailing Address - Street 1:5941 MILLRACE CT UNIT D103
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-7204
Mailing Address - Country:US
Mailing Address - Phone:410-312-3126
Mailing Address - Fax:
Practice Address - Street 1:5941 MILLRACE CT UNIT D103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-7204
Practice Address - Country:US
Practice Address - Phone:410-312-3126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:438-31-0969
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
305R00000X
MD305R00000X
MD0000000000305R00000X
MD30500000X305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization