Basic Information
Provider Information | |||||||||
NPI: | 1710126784 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IMMACULATE HEALTH CARE SERVICES,INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HCA0012 | DC | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 035810300 | 05 | DC |   | MEDICAID |