Provider Demographics
NPI:1700077377
Name:PROVIDENCE PT & DME
Entity Type:Organization
Organization Name:PROVIDENCE PT & DME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GUILLAUME
Authorized Official - Middle Name:SERY
Authorized Official - Last Name:KABERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-277-4337
Mailing Address - Street 1:5810 RIVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-2142
Mailing Address - Country:US
Mailing Address - Phone:301-277-4337
Mailing Address - Fax:301-277-4335
Practice Address - Street 1:5810 RIVERDALE RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-2142
Practice Address - Country:US
Practice Address - Phone:301-277-4337
Practice Address - Fax:301-277-4335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2484332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies