Healthcare Provider Details

I. General information

NPI: 1982437521
Provider Name (Legal Business Name): MANCHESTER MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 PERSHING DR STE 110
SILVER SPRING MD
20910-4439
US

IV. Provider business mailing address

20355 CENTURY BLVD # M
GERMANTOWN MD
20874-1110
US

V. Phone/Fax

Practice location:
  • Phone: 240-338-3290
  • Fax:
Mailing address:
  • Phone: 240-338-3290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TESS LEE
Title or Position: NURSE PRACTITIONER/OWNER
Credential: CRNP
Phone: 240-338-3290