Healthcare Provider Details

I. General information

NPI: 1043067655
Provider Name (Legal Business Name): ISB COMMUNITY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6623 JOHNNYCAKE RD
WINDSOR MILL MD
21244-2401
US

IV. Provider business mailing address

6631 JOHNNYCAKE RD
WINDSOR MILL MD
21244-2401
US

V. Phone/Fax

Practice location:
  • Phone: 410-744-1690
  • Fax: 410-744-1691
Mailing address:
  • Phone: 410-744-1690
  • Fax: 410-744-1691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. FAJR KHOKHAR
Title or Position: PRACTICE MANAGER
Credential:
Phone: 667-802-0425