Healthcare Provider Details

I. General information

NPI: 1649716119
Provider Name (Legal Business Name): EMMANUEL MBAGWU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6316 KINSEY TER
LANHAM MD
20706-2395
US

IV. Provider business mailing address

6316 KINSEY TER
LANHAM MD
20706-2395
US

V. Phone/Fax

Practice location:
  • Phone: 202-327-1514
  • Fax:
Mailing address:
  • Phone: 202-327-1514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA5548
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: