=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902457377
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL TEZEH MUNOH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2019
-----------------------------------------------------
Last Update Date | 09/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3801 KENILWORTH AVE APT 302E
-----------------------------------------------------
City | BLADENSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20710-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-851-9239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3801 KENILWORTH AVE APT 302E
-----------------------------------------------------
City | BLADENSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20710-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-851-9239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | HHA14667
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------