Healthcare Provider Details

I. General information

NPI: 1609647577
Provider Name (Legal Business Name): INTEGRATED MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7404 EXECUTIVE PL STE 100
LANHAM MD
20706-6237
US

IV. Provider business mailing address

3613 CELESTE BRUCE CIR
BOWIE MD
20721-2287
US

V. Phone/Fax

Practice location:
  • Phone: 240-260-3827
  • Fax: 240-260-3830
Mailing address:
  • Phone: 240-260-3827
  • Fax: 240-260-3830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: FLORENCE NGUH
Title or Position: OWNER
Credential: NP
Phone: 240-260-3827