Healthcare Provider Details

I. General information

NPI: 1912975277
Provider Name (Legal Business Name): PACE & LEATHERWOOD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12070 OLD LINE CTR SUITE 302
WALDORF MD
20602-2513
US

IV. Provider business mailing address

PO BOX 249
WALDORF MD
20604-0249
US

V. Phone/Fax

Practice location:
  • Phone: 301-645-6667
  • Fax: 301-870-9722
Mailing address:
  • Phone: 301-645-6667
  • Fax: 301-870-9722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMMY M BREITENBACH
Title or Position: MEDICAL MANAGER
Credential: CMM
Phone: 301-645-6667