Healthcare Provider Details

I. General information

NPI: 1831902915
Provider Name (Legal Business Name): ST. AUGUSTIN HEALTHCARE SERVICES L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 JOUSTING LN
UPPER MARLBORO MD
20772-4388
US

IV. Provider business mailing address

3301 RICHMOND HWY
ALEXANDRIA VA
22305-3044
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 Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MR. BASIL TEGHEN NDUM
Title or Position: MANAGER
Credential: RN
Phone: 240-872-6598