Provider Demographics
NPI:1710689500
Name:MONTGOMERY COUNTY MARYLAND GOVERNMENT
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY MARYLAND GOVERNMENT
Other - Org Name:SOUTH LAKE ELEMENTARY SCHOOL BASED HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:FLAVIA
Authorized Official - Last Name:BUNYENYEZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-579-0206
Mailing Address - Street 1:401 HUNGERFORD DR FL 6
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4154
Mailing Address - Country:US
Mailing Address - Phone:240-777-3482
Mailing Address - Fax:
Practice Address - Street 1:18100 WASHINGTON GROVE LN
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1054
Practice Address - Country:US
Practice Address - Phone:240-740-7330
Practice Address - Fax:301-548-4966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTGOMERY COUNTY SCHOOL BASED HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-17
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local