Provider Demographics
NPI:1750796876
Name:MBI
Entity type:Organization
Organization Name:MBI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HHA
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:WANTEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-725-9450
Mailing Address - Street 1:115 MISSOURI AVE NW APT 4
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-5241
Mailing Address - Country:US
Mailing Address - Phone:202-725-9450
Mailing Address - Fax:
Practice Address - Street 1:115 MISSOURI AVE NW APT 4
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5241
Practice Address - Country:US
Practice Address - Phone:202-725-9450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MBI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA9059320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities