Provider Demographics
NPI:1023776374
Name:SPECTRUM OF HOPE-HEALTH WELLNESS AND COMMUNITY SERVICES
Entity type:Organization
Organization Name:SPECTRUM OF HOPE-HEALTH WELLNESS AND COMMUNITY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ABILA
Authorized Official - Middle Name:V
Authorized Official - Last Name:TAZANU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-850-8955
Mailing Address - Street 1:12303 STARLING LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2835
Mailing Address - Country:US
Mailing Address - Phone:301-957-1382
Mailing Address - Fax:
Practice Address - Street 1:5711 SARVIS AVE STE 100
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1363
Practice Address - Country:US
Practice Address - Phone:301-850-8955
Practice Address - Fax:301-882-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-03
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD008686000Medicaid