Healthcare Provider Details

I. General information

NPI: 1760161236
Provider Name (Legal Business Name): JUSTICE C ENYINNAYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/26/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 BOSTON WAY STE D
LANHAM MD
20706-6327
US

IV. Provider business mailing address

9314 SPRING HOUSE LN APT J
LAUREL MD
20708-3257
US

V. Phone/Fax

Practice location:
  • Phone: 301-918-0200
  • Fax:
Mailing address:
  • Phone: 202-304-5217
  • 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: