Healthcare Provider Details

I. General information

NPI: 1174341978
Provider Name (Legal Business Name): ANDERSON ROY DJEUTIO QUOIMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13117 CRUTCHFIELD AVE # MD
BOWIE MD
20720-3212
US

IV. Provider business mailing address

702 15TH ST NE
WASHINGTON DC
20002-4508
US

V. Phone/Fax

Practice location:
  • Phone: 240-644-3611
  • Fax:
Mailing address:
  • Phone: 202-388-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA200005127
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: