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General NPI Number Information
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NPI Number | 1669912259
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Entity Type | Organization
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Legal Business Name | WORK LIFE PRIMARY CARE LLC
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Dates
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Enumeration Date | 03/01/2017
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Last Update Date | 03/01/2017
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Provider Practice Location Address
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Address Line | 7954 BALTIMORE ANNAPOLIS BLVD SUITE 2-C
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City | GLEN BURNIE
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State | MD
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Zip | 21060-8188
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Country | US
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Telephone | 410-487-6052
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Fax | 443-960-4203
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Provider Business Mailing Address
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Address Line | 7954 BALTIMORE ANNAPOLIS BLVD SUITE 2-C
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City | GLEN BURNIE
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State | MD
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Zip | 21060-8188
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Country | US
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Telephone | 410-487-6052
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Fax | 443-960-4203
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Authorized Official
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Title or Position | OWNER
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Name | BAMOYO NKONGOLO
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Credential | PHYSICIAN ASSISTANT
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Telephone | 302-562-9437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | C03263
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License Number State | MD
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