Healthcare Provider Details

I. General information

NPI: 1275930711
Provider Name (Legal Business Name): KAYGEE40, INCORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2014
Last Update Date: 11/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6911 LAUREL BOWIE RD SUITE #303
BOWIE MD
20715-1712
US

IV. Provider business mailing address

6911 LAUREL BOWIE RD SUITE #303
BOWIE MD
20715-1712
US

V. Phone/Fax

Practice location:
  • Phone: 301-704-5094
  • Fax:
Mailing address:
  • Phone: 301-704-5094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMH-1511
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberMH-1511
License Number StateMD

VIII. Authorized Official

Name: MR. OLUKAYODE TOPE TAIWO
Title or Position: PROGRAM ADMINISTRATOR
Credential: RN, MSN, MBA
Phone: 301-704-5094