MEDICARE: KWANZA CLINIC LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1396539987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KWANZA CLINIC LLC

Provider Business Mailing Address
First Line	:	303 CHERRYSTONE CT
Second Line	:
City	:	REISTERSTOWN
State	:	MD
Zip	:	21136-6211
Country	:	US
Telephone Number	:	757-667-9549
Fax Number	:	410-834-5631

Provider Business Practice Location Address
First Line	:	303 CHERRYSTONE CT
Second Line	:
City	:	REISTERSTOWN
State	:	MD
Zip	:	21136-6211
Country	:	US
Telephone Number	:	757-667-9549
Fax Number	:	410-834-5631

Authorized Official
Title or Position	:	CRNP
Name	:	DR. EDWIN JUMA
Credential	:	DNP, CRNP
Telephone Number	:	757-667-9549

Provider Enumeration Date	:	04/08/2025
Last Update Date	:	04/08/2025

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