Provider Demographics
NPI:1396325940
Name:TAKU, VITALIS SHEWON
Entity type:Individual
Prefix:
First Name:VITALIS
Middle Name:SHEWON
Last Name:TAKU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9973 GOOD LUCK RD
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3279
Mailing Address - Country:US
Mailing Address - Phone:301-532-7987
Mailing Address - Fax:
Practice Address - Street 1:2611 RICHMOND HWY STE 700
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-4016
Practice Address - Country:US
Practice Address - Phone:844-381-4432
Practice Address - Fax:877-763-2165
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant