Healthcare Provider Details

I. General information

NPI: 1285224287
Provider Name (Legal Business Name): POLICAP TENGEN TAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 CHERRY LN STE 212
LAUREL MD
20708-1116
US

IV. Provider business mailing address

9101 CHERRY LN STE 212
LAUREL MD
20708-1116
US

V. Phone/Fax

Practice location:
  • Phone: 301-213-1812
  • Fax:
Mailing address:
  • Phone: 301-213-1812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA00189812
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: