Provider Demographics
NPI:1942544887
Name:AMBOSELI MEDICAL AND WELLNESS CTR
Entity Type:Organization
Organization Name:AMBOSELI MEDICAL AND WELLNESS CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:GASTON
Authorized Official - Last Name:LOUTOBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-660-3035
Mailing Address - Street 1:5425 WISCONSIN AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-3588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8320 FENTON STREET SUITE 122
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910
Practice Address - Country:US
Practice Address - Phone:301-660-3035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0070195261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center