1669723961 NPI number — RFOM NURSE PRACTITIONER CLINIC, LLC

Table of content: (NPI 1669723961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669723961 NPI number — RFOM NURSE PRACTITIONER CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RFOM NURSE PRACTITIONER CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669723961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9656 BRASSIE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY VILLAGE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20886-1910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-447-3204
Provider Business Mailing Address Fax Number:
301-587-3204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8238 GEORGIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILVER SPRING
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20910-4516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-447-3204
Provider Business Practice Location Address Fax Number:
301-587-3204
Provider Enumeration Date:
09/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JEFFERIES
Authorized Official First Name:
STELLA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
240-447-3204

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  R161889 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 050213800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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