MEDICARE: ESSENTIALS SOULON

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	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1013275445	OTHER	MD	1174998009

General Provider Information

NPI Number	:	1174998009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESSENTIALS SOULON

Provider Business Mailing Address
First Line	:	6600 HORSESHOE RD
Second Line	:
City	:	CLINTON
State	:	MD
Zip	:	20735-2537
Country	:	US
Telephone Number	:	202-802-3098
Fax Number	:	301-836-1772

Provider Business Practice Location Address
First Line	:	2736 KEATING ST
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-1512
Country	:	US
Telephone Number	:	202-802-3098
Fax Number	:	301-836-1772

Authorized Official
Title or Position	:	OWNER
Name	:	MS. DEJUAN ANDREA BURNS
Credential	:
Telephone Number	:	202-802-3098

Provider Enumeration Date	:	12/03/2015
Last Update Date	:	12/03/2015

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Directions to “ESSENTIALS SOULON ” Practice Location

Language	Start Address	Practice Location

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