Healthcare Provider Details

I. General information

NPI: 1639967409
Provider Name (Legal Business Name): KING OF GLORY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8861 BRANCH AVE
CLINTON MD
20735-2632
US

IV. Provider business mailing address

9722 NATALIE DR
UPPER MARLBORO MD
20772-4340
US

V. Phone/Fax

Practice location:
  • Phone: 240-448-7242
  • Fax: 240-448-6991
Mailing address:
  • Phone: 240-448-7242
  • Fax: 240-448-6991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IFEYINWA OKAFOR
Title or Position: PRESIDENT
Credential:
Phone: 240-448-7242