Provider Demographics
NPI:1790468817
Name:TEBO, KLUIVERT TEBO
Entity Type:Individual
Prefix:
First Name:KLUIVERT
Middle Name:TEBO
Last Name:TEBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13912 CASTLE BLVD APT 303
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-4949
Mailing Address - Country:US
Mailing Address - Phone:240-755-3404
Mailing Address - Fax:
Practice Address - Street 1:1220 12TH ST SE STE 350
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3727
Practice Address - Country:US
Practice Address - Phone:202-846-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR261917163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse