MEDICARE: VITALIS TEBO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide		DC

General Provider Information

NPI Number	:	1043146962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VITALIS TEBO

Provider Business Mailing Address
First Line	:	3420 DODGE PARK RD APT 104
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-2043
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3420 DODGE PARK RD APT 104
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-2043
Country	:	US
Telephone Number	:	202-528-5776
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2026
Last Update Date	:	06/18/2026

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Directions to “ VITALIS TEBO ” Practice Location

Language	Start Address	Practice Location

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