Healthcare Provider Details

I. General information

NPI: 1346791316
Provider Name (Legal Business Name): CHARLES ONDEPE IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 64TH AVE APT 4
LANDOVER HILLS MD
20784-1860
US

IV. Provider business mailing address

3825 64TH AVE APT 4
LANDOVER HILLS MD
20784-1860
US

V. Phone/Fax

Practice location:
  • Phone: 124-046-7546
  • Fax:
Mailing address:
  • Phone: 124-046-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA12447
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberHHA12447
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: