Healthcare Provider Details

I. General information

NPI: 1255847588
Provider Name (Legal Business Name): MR. KEM BUMBARA MARK-IVO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10016 ELLARD DR
LANHAM MD
20706-2051
US

IV. Provider business mailing address

10016 ELLARD DR
LANHAM MD
20706-2051
US

V. Phone/Fax

Practice location:
  • Phone: 240-595-9915
  • Fax:
Mailing address:
  • Phone: 240-595-9915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: