Healthcare Provider Details

I. General information

NPI: 1467386656
Provider Name (Legal Business Name): DIVINE TAKO EBAI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 ETHAN ALLEN AVE
TAKOMA PARK MD
20912-5400
US

IV. Provider business mailing address

614 ETHAN ALLEN AVE
TAKOMA PARK MD
20912-5400
US

V. Phone/Fax

Practice location:
  • Phone: 240-458-8832
  • Fax:
Mailing address:
  • Phone: 240-458-8832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: