Healthcare Provider Details

I. General information

NPI: 1295664670
Provider Name (Legal Business Name): ST. AUGUSTIN HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/31/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 JOUSTING LN
UPPER MARLBORO MD
20772-4388
US

IV. Provider business mailing address

9105 JOUSTING LN
UPPER MARLBORO MD
20772-4388
US

V. Phone/Fax

Practice location:
  • Phone: 240-872-6598
  • Fax:
Mailing address:
  • Phone: 240-872-6598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BASIL TEGHEN NDUM
Title or Position: CEO
Credential:
Phone: 240-872-6598