Healthcare Provider Details

I. General information

NPI: 1154724094
Provider Name (Legal Business Name): ESSENTIALS SOUL-ON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7902 OLD BRANCH AVE 105
CLINTON MD
20735-1646
US

IV. Provider business mailing address

6600 HORSESHOE RD
CLINTON MD
20735-2537
US

V. Phone/Fax

Practice location:
  • Phone: 202-802-3098
  • Fax:
Mailing address:
  • Phone: 202-802-3098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number425560
License Number StateMD

VIII. Authorized Official

Name: MS. DEJUAN BURNS
Title or Position: OWNER
Credential:
Phone: 202-802-3098