MEDICARE: ICS

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	3104A0625X	Assisted Living Facility (Mental Illness)	HHA10972	DC

General Provider Information

NPI Number	:	1194128819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICS

Provider Business Mailing Address
First Line	:	1234 SOUTHERN AVE SE APT 301
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20032-4620
Country	:	US
Telephone Number	:	240-467-4139
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 SOUTHERN AVE SE APT 301
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20032-4620
Country	:	US
Telephone Number	:	240-467-4139
Fax Number	:

Authorized Official
Title or Position	:	HHA
Name	:	CLOTILDE ANDJONGO BITOMO
Credential	:
Telephone Number	:	240-467-4139

Provider Enumeration Date	:	10/08/2014
Last Update Date	:	10/08/2014

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Directions to “ICS ” Practice Location

Language	Start Address	Practice Location

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