1689032187 NPI number — WAVECARE HEALTH SERVICES LLC

Table of content: (NPI 1689032187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689032187 NPI number — WAVECARE HEALTH SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAVECARE HEALTH SERVICES 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:
1689032187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11900 LISBOROUGH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20720-3405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-237-1141
Provider Business Mailing Address Fax Number:
202-388-9555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8725 GREENBELT RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
GREENBELT
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20770-2475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-388-9555
Provider Business Practice Location Address Fax Number:
202-388-9558
Provider Enumeration Date:
01/29/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKMAN
Authorized Official First Name:
WAVENEY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
301-237-1141

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  R3786 , 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: 039537200 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 421615600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com