MEDICARE: KENAH ONE HEALTH CARE SERVICES, LLC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1164266813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENAH ONE HEALTH CARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	7735 HOLLINS CHAPEL CT
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21060-8396
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 WASHINGTON AVE
Second Line	:
City	:	CHESTERTOWN
State	:	MD
Zip	:	21620-1257
Country	:	US
Telephone Number	:	240-712-8881
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KETTY M NGONA
Credential	:
Telephone Number	:	443-465-9958

Provider Enumeration Date	:	06/19/2024
Last Update Date	:	06/19/2024

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