Healthcare Provider Details

I. General information

NPI: 1669809737
Provider Name (Legal Business Name): THE 1091 GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2013
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 KINGSTOWNE CENTER DRIVE #120-146
ALEXANDRIA VA
22315-5711
US

IV. Provider business mailing address

5810 KINGSTOWNE CENTER DRIVE #120-146
ALEXANDRIA VA
22315-5711
US

V. Phone/Fax

Practice location:
  • Phone: 703-798-7826
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: MR. IBRAHIM TEJAN KARGBO
Title or Position: FOUNDER/OWNER
Credential: M.P.H
Phone: 703-798-7826