Healthcare Provider Details

I. General information

NPI: 1245951276
Provider Name (Legal Business Name): GENERATIONAL HEALTH COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 RHODE ISLAND AVE NE STE D
WASHINGTON DC
20002-1299
US

IV. Provider business mailing address

617 RHODE ISLAND AVE NE STE D
WASHINGTON DC
20002-1299
US

V. Phone/Fax

Practice location:
  • Phone: 202-486-1152
  • Fax:
Mailing address:
  • Phone: 202-486-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KIMBERLY M BURRIS
Title or Position: WOUND CARE ASSOCIATE
Credential: WCA
Phone: 202-486-1152