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General NPI Number Information
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NPI Number | 1154724094
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Entity Type | Organization
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Legal Business Name | ESSENTIALS SOUL-ON LLC
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Dates
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Enumeration Date | 10/07/2014
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Last Update Date | 10/07/2014
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Provider Practice Location Address
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Address Line | 7902 OLD BRANCH AVE 105
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City | CLINTON
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State | MD
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Zip | 20735-1646
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Country | US
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Telephone | 202-802-3098
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Fax |
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Provider Business Mailing Address
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Address Line | 6600 HORSESHOE RD
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City | CLINTON
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State | MD
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Zip | 20735-2537
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Country | US
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Telephone | 202-802-3098
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. DEJUAN BURNS
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Credential |
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Telephone | 202-802-3098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 425560
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License Number State | MD
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