Healthcare Provider Details

I. General information

NPI: 1295910891
Provider Name (Legal Business Name): LAKEWOOD HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MERCANTILE LN STE 180
LARGO MD
20774-5369
US

IV. Provider business mailing address

1400 MERCANTILE LN STE 180
LARGO MD
20774-5369
US

V. Phone/Fax

Practice location:
  • Phone: 301-925-7002
  • Fax: 301-925-4463
Mailing address:
  • Phone: 301-925-7002
  • Fax: 301-925-4463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MONISOLA ADEYEMO
Title or Position: NP
Credential:
Phone: 301-925-7022