1740466507 NPI number — PROGRESSIVE HABILITATIVE SERVICES INC. II

Table of content: (NPI 1740466507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740466507 NPI number — PROGRESSIVE HABILITATIVE SERVICES INC. II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE HABILITATIVE SERVICES INC. II
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:
1740466507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13629 BALTIMORE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUREL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20707-5095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-317-9996
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6407 CHILLUM PL. N,W.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-291-3672
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KOKER
Authorized Official First Name:
MAUDE-MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
C E O
Authorized Official Telephone Number:
301-681-8312

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 038479400 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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