Healthcare Provider Details

I. General information

NPI: 1558813287
Provider Name (Legal Business Name): COLIN MEKOLE MOTITI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 RUSSELL AVE
MOUNT RAINIER MD
20712-1720
US

IV. Provider business mailing address

4207 RUSSELL AVE
MOUNT RAINIER MD
20712-1720
US

V. Phone/Fax

Practice location:
  • Phone: 301-624-9705
  • Fax:
Mailing address:
  • Phone: 301-624-9705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: