Healthcare Provider Details

I. General information

NPI: 1396400248
Provider Name (Legal Business Name): GUH KIDS MOBILE MEDICAL CLINIC PROGRAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WISCONSIN AVE NW STE 400
WASHINGTON DC
20016-2100
US

IV. Provider business mailing address

3800 RESERVOIR RD NW
WASHINGTON DC
20007-2113
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-8888
  • Fax: 202-444-4315
Mailing address:
  • Phone: 703-558-1217
  • Fax: 703-558-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE SCHNEIDER
Title or Position: VP
Credential:
Phone: 702-558-1403