Provider Demographics
NPI:1922576578
Name:EBOUE EBOUE, DIMITH PRIERY
Entity Type:Individual
Prefix:
First Name:DIMITH PRIERY
Middle Name:
Last Name:EBOUE EBOUE
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 1:20 RITCHIE AVE APT 33
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-5129
Mailing Address - Country:US
Mailing Address - Phone:202-445-5638
Mailing Address - Fax:
Practice Address - Street 1:20 RITCHIE AVE APT 33
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-5129
Practice Address - Country:US
Practice Address - Phone:202-445-5638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14123374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide