Provider Demographics
NPI:1710699137
Name:AGLOW RECOVERY HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:AGLOW RECOVERY HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERNIBA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:GHONEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-621-8713
Mailing Address - Street 1:2490 MARKET ST NE # 630
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-3851
Mailing Address - Country:US
Mailing Address - Phone:202-621-8713
Mailing Address - Fax:202-946-7091
Practice Address - Street 1:1647 BENNING RD NE STE 300A
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4572
Practice Address - Country:US
Practice Address - Phone:202-621-8713
Practice Address - Fax:202-946-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty