Healthcare Provider Details

I. General information

NPI: 1861963779
Provider Name (Legal Business Name): GREGORY MICHAEL TERRELL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 OLIVE ST NE APT 1
WASHINGTON DC
20019-2738
US

IV. Provider business mailing address

1615 OLIVE ST NE APT 1
WASHINGTON DC
20019-2738
US

V. Phone/Fax

Practice location:
  • Phone: 202-459-3357
  • Fax:
Mailing address:
  • Phone: 202-459-3357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: