MEDICARE: DERQUACIA BLACK

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	3747P1801X	Personal Care Attendant		DC

General Provider Information

NPI Number	:	1548117518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERQUACIA BLACK

Provider Business Mailing Address
First Line	:	2005 EVARTS ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20018-2115
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 EVARTS ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20018-2115
Country	:	US
Telephone Number	:	786-414-8624
Fax Number	:

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

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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Directions to “ DERQUACIA BLACK ” Practice Location

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