Provider Demographics
NPI:1851441695
Name:KACC
Entity Type:Organization
Organization Name:KACC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-677-8949
Mailing Address - Street 1:2480 LLEWELLYNE AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5800
Practice Address - Country:US
Practice Address - Phone:301-677-8949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center