Healthcare Provider Details

I. General information

NPI: 1033955414
Provider Name (Legal Business Name): MAMBO ROYAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 KING CENTRE DR STE 600
ALEXANDRIA VA
22315-5755
US

IV. Provider business mailing address

5680 KING CENTRE DR STE 600
ALEXANDRIA VA
22315-5755
US

V. Phone/Fax

Practice location:
  • Phone: 240-413-1407
  • Fax:
Mailing address:
  • Phone: 240-413-1407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: GERALDINE NGESAH MAMBO
Title or Position: CEO
Credential:
Phone: 240-413-1407