Provider Demographics
NPI:1629230222
Name:FOGRACE HEALTHCARE, INC
Entity Type:Organization
Organization Name:FOGRACE HEALTHCARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FOLASHADE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMUREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-832-4323
Mailing Address - Street 1:3203 SHORTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2574
Mailing Address - Country:US
Mailing Address - Phone:240-832-4315
Mailing Address - Fax:301-249-9568
Practice Address - Street 1:3203 SHORTRIDGE LN
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-2574
Practice Address - Country:US
Practice Address - Phone:240-832-4315
Practice Address - Fax:301-249-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2031R251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7714131-00Medicaid