Healthcare Provider Details

I. General information

NPI: 1700077377
Provider Name (Legal Business Name): PROVIDENCE PT & DME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 RIVERDALE RD
RIVERDALE MD
20737-2142
US

IV. Provider business mailing address

5810 RIVERDALE RD
RIVERDALE MD
20737-2142
US

V. Phone/Fax

Practice location:
  • Phone: 301-277-4337
  • Fax: 301-277-4335
Mailing address:
  • Phone: 301-277-4337
  • Fax: 301-277-4335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberR2484
License Number StateMD

VIII. Authorized Official

Name: MR. GUILLAUME SERY KABERT
Title or Position: CEO, PRESIDENT
Credential:
Phone: 301-277-4337