Healthcare Provider Details

I. General information

NPI: 1083878730
Provider Name (Legal Business Name): PHS CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 VARNUM ST NE SUITE 201
WASHINGTON DC
20017-2104
US

IV. Provider business mailing address

1160 VARNUM ST NE ST CATHERINE'S HALL, ROOM 102
WASHINGTON DC
20017-2107
US

V. Phone/Fax

Practice location:
  • Phone: 202-854-7674
  • Fax: 202-269-7825
Mailing address:
  • Phone: 202-854-4069
  • Fax: 202-854-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberHFD01-0212
License Number StateDC

VIII. Authorized Official

Name: BEAU HIGGINBOTHAM
Title or Position: VP
Credential:
Phone: 410-368-3168