Healthcare Provider Details

I. General information

NPI: 1578729331
Provider Name (Legal Business Name): ENVISIONCARE MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10507 MONTANA TER
UPPER MARLBORO MD
20774-6034
US

IV. Provider business mailing address

1400 MERCANTILE LN SUITE 124
LARGO MD
20774-5341
US

V. Phone/Fax

Practice location:
  • Phone: 301-237-7383
  • Fax: 301-322-9555
Mailing address:
  • Phone: 301-322-9292
  • Fax: 301-322-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberNP117688
License Number StateMD

VIII. Authorized Official

Name: CHINWE N NDUBISI
Title or Position: MEDICAL PRACTITIONER
Credential: MSN, CRNP-F, ARNP-F
Phone: 301-237-7383