Healthcare Provider Details

I. General information

NPI: 1982421095
Provider Name (Legal Business Name): CCM HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2024
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42925 HUNGERFORD CT
HOLLYWOOD MD
20636-3278
US

IV. Provider business mailing address

42925 HUNGERFORD CT
HOLLYWOOD MD
20636-3278
US

V. Phone/Fax

Practice location:
  • Phone: 240-718-4820
  • Fax: 657-699-1592
Mailing address:
  • Phone: 775-771-6830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. GRETCHEN ANN MACHESNEY
Title or Position: OWNER
Credential: NP
Phone: 240-718-4820