1174998009 NPI number — ESSENTIALS SOULON

Table of content: (NPI 1174998009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174998009 NPI number — ESSENTIALS SOULON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESSENTIALS SOULON
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:
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:
1174998009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6600 HORSESHOE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20735-2537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-802-3098
Provider Business Mailing Address Fax Number:
301-836-1772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2736 KEATING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE HILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20748-1512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-802-3098
Provider Business Practice Location Address Fax Number:
301-836-1772
Provider Enumeration Date:
12/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BURNS
Authorized Official First Name:
DEJUAN
Authorized Official Middle Name:
ANDREA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
202-802-3098

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1013275445 . This is a "1174998009" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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