MEDICARE: MR. HAITAM M ABUGHRARA

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	343900000X	Non-emergency Medical Transport (VAN)	B65301570	VA

General Provider Information

NPI Number	:	1538903745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HAITAM M ABUGHRARA

Provider Business Mailing Address
First Line	:	5422 ECHOLS AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22311-1343
Country	:	US
Telephone Number	:	571-494-7896
Fax Number	:

Provider Business Practice Location Address
First Line	:	5422 ECHOLS AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22311-1343
Country	:	US
Telephone Number	:	571-494-7896
Fax Number	:

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

Provider Enumeration Date	:	06/21/2024
Last Update Date	:	06/21/2024

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