Provider Demographics
NPI:1134155583
Name:LHCA'S DIABETES DISEASE STATE MANAGEMENT CENTER
Entity type:Organization
Organization Name:LHCA'S DIABETES DISEASE STATE MANAGEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:E
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD, LICSW
Authorized Official - Phone:301-942-0678
Mailing Address - Street 1:3116 FESSENDEN ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-2029
Mailing Address - Country:US
Mailing Address - Phone:301-942-0678
Mailing Address - Fax:301-942-0079
Practice Address - Street 1:3937 FERRARA DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-4709
Practice Address - Country:US
Practice Address - Phone:301-942-0678
Practice Address - Fax:301-942-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC595266Medicare ID - Type UnspecifiedDC, MD, NO. VIRGINIA
DCDC0386Medicare ID - Type UnspecifiedDC, MD, NO VIRGINIA