Provider Demographics
NPI:1699220731
Name:SIMPLY 4 KIDZ HEALTHCARE, LLC
Entity Type:Organization
Organization Name:SIMPLY 4 KIDZ HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LUM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:240-513-4595
Mailing Address - Street 1:265 MILL ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6130
Mailing Address - Country:US
Mailing Address - Phone:240-513-4595
Mailing Address - Fax:240-513-4596
Practice Address - Street 1:265 MILL ST
Practice Address - Street 2:SUITE 800
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6130
Practice Address - Country:US
Practice Address - Phone:240-513-4595
Practice Address - Fax:240-513-4596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR109055363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD807602200Medicaid