MEDICARE: LHCA'S DIABETES DISEASE STATE MANAGEMENT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1134155583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LHCA'S DIABETES DISEASE STATE MANAGEMENT CENTER

Provider Business Mailing Address
First Line	:	3116 FESSENDEN ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20008-2029
Country	:	US
Telephone Number	:	301-942-0678
Fax Number	:	301-942-0079

Provider Business Practice Location Address
First Line	:	3937 FERRARA DR
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906-4709
Country	:	US
Telephone Number	:	301-942-0678
Fax Number	:	301-942-0079

Authorized Official
Title or Position	:	CEO
Name	:	DR. LEO E HENDRICKS JR.
Credential	:	PHD, LICSW
Telephone Number	:	301-942-0678

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	08/22/2020

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