Healthcare Provider Details

I. General information

NPI: 1558668947
Provider Name (Legal Business Name): FESCUM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2011
Last Update Date: 02/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6304 WILLOW WAY
CLINTON MD
20735-3956
US

IV. Provider business mailing address

6304 WILLOW WAY
CLINTON MD
20735-3956
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-5217
  • Fax:
Mailing address:
  • Phone: 301-877-5217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberLP41520
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberLP41520
License Number StateDC

VIII. Authorized Official

Name: MR. FOLORUNSO PAUL IJITI
Title or Position: DIRECTOR
Credential: BSC SOCILOGY, NURSE
Phone: 301-442-2521