Provider Demographics
NPI:1184309197
Name:EXPRESS HOME & RENAL HEALTHCARE, LLC.
Entity type:Organization
Organization Name:EXPRESS HOME & RENAL HEALTHCARE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:M
Authorized Official - Last Name:M FON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:301-704-2667
Mailing Address - Street 1:10400 CONNECTICUT AVE STE 602
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-3909
Mailing Address - Country:US
Mailing Address - Phone:301-825-5900
Mailing Address - Fax:301-825-5888
Practice Address - Street 1:10400 CONNECTICUT AVE STE 602
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-3909
Practice Address - Country:US
Practice Address - Phone:301-825-5900
Practice Address - Fax:301-825-5888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5587216200Medicaid