Healthcare Provider Details

I. General information

NPI: 1750911798
Provider Name (Legal Business Name): DIABETES SELF CARE MANAGEMENT INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 TOLEDO TER STE B103
HYATTSVILLE MD
20782-8146
US

IV. Provider business mailing address

3311 TOLEDO TER STE B103
HYATTSVILLE MD
20782-8146
US

V. Phone/Fax

Practice location:
  • Phone: 301-245-3082
  • Fax: 301-978-7986
Mailing address:
  • Phone: 301-245-3082
  • Fax: 301-978-7986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MARJORIE RAY MADIKOTO
Title or Position: PROVIDER
Credential: CFNP
Phone: 301-245-3082