Provider Demographics
NPI:1710126784
Name:IMMACULATE HEALTH CARE SERVICES,INC
Entity Type:Organization
Organization Name:IMMACULATE HEALTH CARE SERVICES,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:OSUJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-832-8340
Mailing Address - Street 1:1818 NEW YORK AVE NE
Mailing Address - Street 2:SUITE 228
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1848
Mailing Address - Country:US
Mailing Address - Phone:202-832-8340
Mailing Address - Fax:202-832-8341
Practice Address - Street 1:12817 ODENS BEQUEST DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720
Practice Address - Country:US
Practice Address - Phone:202-832-8340
Practice Address - Fax:202-832-8341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHCA0012251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC035810300Medicaid