Provider Demographics
NPI:1912431743
Name:MOUNT CLARE HEALTHCHOICES, LLC
Entity Type:Organization
Organization Name:MOUNT CLARE HEALTHCHOICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAE HOON
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-929-6334
Mailing Address - Street 1:3460 QUEENSBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-2545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20300 SENECA MEADOWS PKWY STE 215
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-7021
Practice Address - Country:US
Practice Address - Phone:410-929-6334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR189134261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD587108500Medicaid
274315ZAF1Medicare PIN