Healthcare Provider Details

I. General information

NPI: 1356763767
Provider Name (Legal Business Name): LIFE BRIDGE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 OLIVINE CT
SILVER SPRING MD
20904-5323
US

IV. Provider business mailing address

1909 OLIVINE CT
SILVER SPRING MD
20904-5323
US

V. Phone/Fax

Practice location:
  • Phone: 240-476-1069
  • Fax:
Mailing address:
  • Phone: 240-476-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License NumberC0005298
License Number StateMD

VIII. Authorized Official

Name: DANIEL TSIGE TAMERAT
Title or Position: PA-C
Credential:
Phone: 240-476-1069