Healthcare Provider Details

I. General information

NPI: 1972809911
Provider Name (Legal Business Name): GOOD HEALTH NUTRITION SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7515 ANNAPOLIS RD STE 402
HYATTSVILLE MD
20784-1752
US

IV. Provider business mailing address

7515 ANNAPOLIS RD STE 402
HYATTSVILLE MD
20784-1752
US

V. Phone/Fax

Practice location:
  • Phone: 301-577-1072
  • Fax: 301-577-1073
Mailing address:
  • Phone: 301-577-1072
  • Fax: 301-577-1073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberDX 2507
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberDX2507
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberDX2507
License Number StateMD

VIII. Authorized Official

Name: MRS. FLORENCE IFEOMA OMERENNAH
Title or Position: PRESIDENT
Credential: D.O,
Phone: 301-577-1072