Healthcare Provider Details

I. General information

NPI: 1831417476
Provider Name (Legal Business Name): CIVISTA CLINICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11315 PEMBROOKE SQ STE 111
WALDORF MD
20603-4806
US

IV. Provider business mailing address

5 GARRETT AVENUE PO BOX 1070
LA PLATA MD
20646-1070
US

V. Phone/Fax

Practice location:
  • Phone: 301-843-3150
  • Fax: 301-843-2560
Mailing address:
  • Phone: 301-609-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberD0065304
License Number StateMD

VIII. Authorized Official

Name: MRS. IVETTE M MONTES DE OCA
Title or Position: PRACTICE MANAGER
Credential:
Phone: 301-843-3150