Basic Information
| Provider Information | |||||||||
| NPI: | 1578929956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMUEL | ||||||||
| FirstName: | VERNON | ||||||||
| MiddleName: | |||||||||
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| Credential: | HHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 GUNTHER ST | ||||||||
| Address2: | |||||||||
| City: | CAPITOL HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207434024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025569800 | ||||||||
| FaxNumber: | 2026355780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1731 BUNKER HILL RD NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200173026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024078909 | ||||||||
| FaxNumber: | 2026355780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2016 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 374U00000X | HHA11475 | DC | Y | Nursing Service Related Providers | Home Health Aide |
ID Information
| ID | Type | State | Issuer | Description | HHA11475 | 01 | DC | HOME HEALTH AIDE | OTHER |