MEDICARE: AGBORTOKO GRACE MBENGETA

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	374U00000X	Home Health Aide	HHA200004124	DC

General Provider Information

NPI Number	:	1427884030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGBORTOKO GRACE MBENGETA

Provider Business Mailing Address
First Line	:	11700 OLD COLUMBIA PIKE APT 1908
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20904-2558
Country	:	US
Telephone Number	:	346-242-9560
Fax Number	:

Provider Business Practice Location Address
First Line	:	11700 OLD COLUMBIA PIKE APT 1908
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20904-2558
Country	:	US
Telephone Number	:	346-242-9560
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2024
Last Update Date	:	09/10/2024

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