Healthcare Provider Details

I. General information

NPI: 1710683156
Provider Name (Legal Business Name): CHIVIC HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 09/05/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9470 ANNAPOLIS RD STE 416
LANHAM MD
20706-3000
US

IV. Provider business mailing address

9470 ANNAPOLIS RD STE 416
LANHAM MD
20706-3000
US

V. Phone/Fax

Practice location:
  • Phone: 202-735-1010
  • Fax:
Mailing address:
  • Phone: 202-735-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NDIDIAMAKA EZINNE MBAKPUO
Title or Position: CEO
Credential:
Phone: 301-712-4637