Basic Information
Provider Information
NPI: 1710126784
EntityType: 2
ReplacementNPI:  
OrganizationName: IMMACULATE HEALTH CARE SERVICES,INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: 1818 NEW YORK AVE NE
Address2: SUITE 228
City: WASHINGTON
State: DC
PostalCode: 200021848
CountryCode: US
TelephoneNumber: 2028328340
FaxNumber: 2028328341
Practice Location
Address1: 12817 ODENS BEQUEST DR
Address2:  
City: BOWIE
State: MD
PostalCode: 20720
CountryCode: US
TelephoneNumber: 2028328340
FaxNumber: 2028328341
Other Information
ProviderEnumerationDate: 02/13/2009
LastUpdateDate: 02/13/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: OSUJI
AuthorizedOfficialFirstName: KENNETH
AuthorizedOfficialMiddleName: .A.
AuthorizedOfficialTitleorPosition: ADMINISTRATOR
AuthorizedOfficialTelephone: 2028328340
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251E00000XHCA0012DCY AgenciesHome Health 

ID Information
IDTypeStateIssuerDescription
03581030005DC MEDICAID


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