Provider Demographics
NPI:1205429131
Name:PROLORD HEALTHCARE AND NURSING SERVICES
Entity type:Organization
Organization Name:PROLORD HEALTHCARE AND NURSING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUSEYI
Authorized Official - Middle Name:
Authorized Official - Last Name:SOFOLUWE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:301-675-3270
Mailing Address - Street 1:13110 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3745
Mailing Address - Country:US
Mailing Address - Phone:301-675-3270
Mailing Address - Fax:240-202-3783
Practice Address - Street 1:13110 3RD ST
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-3745
Practice Address - Country:US
Practice Address - Phone:301-675-3270
Practice Address - Fax:240-202-3783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD143240100Medicaid